“Association Between Quality Improvement for Care Transitions in
Communities and Rehospitalizations Among Medicare Beneficiaries


Centers for Medicare & Medicaid Services' Quality Improvement
Organizations to Improve Care Transitions in 14 Communities





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Brock et al., “Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries”

– JAMA, Jan 23, 2013


Why focus on care transitions?

Care transitions—when patients move from one care setting to another—mark perilous points in patient care. As many as 20% of Medicare fee-for-service beneficiaries are readmitted to the hospital within 30 days of discharge, and, for the most part, these hospitalizations appear to be preventable.

What goes wrong? Poor care coordination, shortcomings in patient preparation, problems in medication management, breakdowns in provider communication, and inadequate support in the community contribute to problems in transitions. Overall, medical errors occur frequently, and contribute to patient suffering.

These problems also lead to unnecessary costs to the Medicare program. Thus, improving care transitions can improve patient care and experience, while reducing costs.

Widespread recognition of this opportunity has led to a remarkable convergence of efforts to support improvement. Payers like Medicare and private insurance companies are creating incentives such as penalties for hospitals with high readmission rates and payment for physicians to coordinate care during transitions. The results reported in this publication have informed major national efforts now underway to improve care transitions, including the Partnership for Patients, the Community-Based Care Transitions Program and community projects in every state through Medicare’s Quality Improvement Organizations (QIOs).

Medicare and the Agency for Healthcare Research and Quality are working together on ways to measure the quality of care transitions and care coordination. The Administration for Community Living is supporting Area Agencies on Aging as partners to enhance this community support and thousands of clinicians are stepping up to the plate to undertake enhancements to their protocols and practices. And, of course, people who have to use hospitals and nursing homes are benefiting!

What happened in the project being reported?

The Centers for Medicare & Medicaid Services (CMS) selected 14 QIOs to participate in a 3-year project to use quality improvement strategies to improve care transitions. Under contract with CMS, QIOs in each state and territory help achieve national quality goals through focused efforts at the community level. QIOs work to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.

For this project, the 14 QIOs facilitated community-wide quality improvement activities to implement evidence-based improvements in care transitions. Their efforts included community organizing, technical assistance in implementing best practices, and monitoring of participation, implementation, effectiveness, and adverse effects.

Each community used strategies that targeted its own particular circumstances, so interventions varied among the 14 sites. The project tracked progress using a management tool called “process control charts.” The primary measure was all-cause 30-day rehospitalizations per 1000 Medicare fee-for-service beneficiaries living in the community; a secondary measure looked at all-cause hospitalizations among this same group. The project also reported all-cause 30-day rehospitalizations as a percentage of hospital discharges. And they also tracked patient satisfaction, mortality, and displacement of utilization to emergency rooms and other services.

To better monitor trends, the project also tracked these same factors in 50 comparison communities, where there were no interventions sponsored.


The main finding is that hospitalizations and rehospitalizations declined nearly twice as fast in the intervention communities as in the comparison sites. There was no adverse effect upon patient-reported measures of satisfaction with services, mortality, or utilization of other services.

What makes the project unusual?

The project took an unusual approach to improving care transitions. Rather than focus on one hospital ward, or one hundred patients, it engaged whole communities to improve care for large geographically defined populations.

Traditionally, hospital services and community services do not often collaborate on procedural and capacity issues—a gap that creates problems for care transitions. To bridge this gap, each community’s project enlisted social service agencies, such as Area Agencies on Aging, along with an array of health care providers, including long-term care facilities, home care agencies, and hospices. This structure enabled participants to work together to set and to reach shared goals. They learned more about one another’s operations, their role in shaping care transitions and they developed coalitions to better manage care for their patient population.

Throughout the project, rather than implement and analyze a single, rigorous intervention, teams constantly reviewed their progress and tailored activities to find improvements that really mattered to patients.

A First for JAMA?

This paper may mark the first time that one of the most widely circulated American medical journals has published a project that used quality improvement (QI) methodologies to measure and report outcomes. It is probably the first time such a journal has published process control charts. This approach is a marked difference from the formality and context-blind randomized clinical trial. In quality improvement, participants take their system as it is and aim to change processes that improve it, rather than setting up a test of whether a particular intervention is effective. Publishing QI work represents a profound change in the openness of American medicine to learn not only what works for a patient but what works for the delivery system.

What is the quality improvement (QI) approach?

The 14 QIOs helped communities convene and facilitate community coalitions and workgroups comprised of medical and non-medical service providers and supplied them with QI expertise and tools. The QIOs used Medicare claims data, medical record reviews, and process assessments to understand the causes of rehospitalizations and worked with communities to select evidence-based best practices connecting them to leaders in the field and other experts.

The teams used rapid-cycle quality improvement techniques (plan-do-study-act) to test changes and to track their progress, thereby being able to learn from the effects of their interventions. QIO staff helped communities interpret the data they collected, modify their approaches, discontinue those that showed no effect, and incorporate those that did.

Did it work?

This approach appears to be effective. Key results include:
1.    The 14 intervention communities had a mean reduction of 5.70% rehospitalizations per 1000 Medicare FFS beneficiaries.
2.    The 14 communities also had a mean reduction of 5.74% in hospitalizations per 1000 Medicare FFS beneficiaries.
3.    The widely used measure of rehospitalizations as a percentage of hospital discharges did not change.
4.    An average community of 50,000 Medicare fee-for-service beneficiaries would have saved Medicare more than $4 million per community per year (see the eAppendix), while the cost per site averaged less than $1 million per year.

Why did it work?

We don’t have enough experience to be sure, but we have some hunches from watching how things worked out:
1.    The work focused on every Medicare beneficiary in the community, not just those with particular illnesses or in particular hospitals or insurance plans. Therefore, the teams had to improve their patterns of care at the time of transition, not just stretch to make things work for a small number of patients.
2.    The work built relationships. Hospital clinicians came to know those who provided after-hospital support, for example. Professionals who participate in care transitions confronted the often-unnoticed effects of errors “in the gaps” between services and were motivated by the unnecessary suffering of their patients, clients, and families.
3.    QIOs provided technical assistance, quality improvement expertise and the support for meetings and shared work. The U.S. does not have ready-made organizations that bear responsibility for the well-being of ill and disabled people across settings and time. The coalitions that formed accepted this responsibility.
4.    The project was set up to be flexible and respond to the priorities and capabilities of each community. Provider participation in the project was voluntary, so it had to become important enough and easy enough to get involved. One approach to address care transitions was to focus on improving communication between all providers in the community. Another was to standardize the processes so that shortcomings that had previously been tolerated and overlooked became errors that were obvious in a standard process.

What does this work mean for other communities?

Efforts to build on this work are already underway, such as the Partnership for Patients, the Community-based Care Transitions Program, and through the care transitions work being done by QIOs throughout the U.S. Hospitals with high readmission rates face financial penalties; physicians are now able to bill Medicare for care coordination activities. In the current 3-year cycle of work, every QIO has been asked to foster coalition-based approaches to reducing rehospitalizations; nearly 400 communities are already involved in the current work. With the results here, any care transitions improvement project now must take into account the possibility of having a good effect upon hospitalizations, not just rehospitalizations. Some initiatives may choose to measure care transitions quality more directly, as well as monitoring hospital use.




Brock et al., “Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries”
– JAMA, Jan 23, 2013


Patrick Conway, MD, MSc
Centers for Medicare & Medicaid Services, Chief Medical Officer
Director, CMS Center for Clinical Standards & Quality
Media contact: Kelly Anderson at Kelly.anderson@cms.hhs.gov

“We are pleased to see that JAMA’s editors agree that CMS’ quality improvement approach to reduce 30-day rehospitalizations is grounded in scientifically sound principles. This article validates the community-based approach we at CMS are taking in our current work to improve how patients transition from the hospital to care in their homes or elsewhere in the communities. What sets our community-based approach apart is two-fold: first, we work with everyone who touches a patient about to leave the hospital—not just the hospital itself. We unite social service agencies, families, faith-based groups, and anyone else who can support you as you transition from hospital to home. Secondly, this approach works because we are able to monitor it with real-time data and analyze it in ways that let us know quickly whether our work makes an impact. And if we see that it isn’t, we can make course corrections early in the process—we don’t wait for our funding to end before we assess whether we could make a difference for the 2.6 million seniors who end up back in the hospital every year because their illness returned after they left the first time.

"In fact, we have already put the results of this project to work. Beginning in August 2011, CMS put its Quality Improvement Organizations (QIOs) to work in over 400 communities across the country to pioneer how the medical community measures readmissions and combats them through quality improvement work. We expanded our work from 14 states to 53 states and territories, which we hope will make even larger contributions to the hospitalization and readmission reduction effort going forward. Providers and communities that team with QIOs have access to groundbreaking innovations in delivery system reform that can translate to real-world impacts for beneficiaries and taxpayers.”

“The QIOs’ work in this project shows a reduction in hospitalization and rehospitalization rates, which are vitally important for keeping Medicare beneficiaries as healthy as possible for as long as possible. This project demonstrates that QIOs can build social capital in communities towards a noble goal—taking care of their own. Thanks to QIOs, these communities created networks of clinicians, facilities, families, social services agencies, and others that share a common language in coordinating care for patients—the community’s sickest and most vulnerable people. These communities effectively prevented hospitalizations, resulting in people being more likely to stay
home and healthy.”

Mark McClellan, MD, PhD
Former CMS Administrator, at the launch of the project

“This study is important in several notable ways. It evaluated the impact of community-wide interventions, which are hard to study. It addressed a critical and common problem in health care – the problem of re-hospitalizations. And it reached a clear conclusion – Medicare's quality improvement program made a real difference. This study is a model for how to generate needed evidence on how local collaborations can best work to improve care.”

Eric A. Coleman, MD, MPH
Director, Care Transitions Program

“This seminal project amplifies the importance of conceiving improving care transitions as a “team sport” anchored in local communities. It further highlights the leadership QIOs can provide as valued partners that convene diverse stakeholders and empower them with the requisite tools, evidence, and data to drive effective results.”

Stephen F. Jencks, MD, MPH
Consultant in Healthcare Safety & Quality
Formerly, the CMS official responsible for the QIO program

“This is really so impressive…. You have produced a model, I think, of how to do as well as possible in examining a real-world test of an innovative effort to improve care.”

“The results may be even more important for their measurement implications than a test of a specific intervention. Reading your results, I think it seems urgent to balance readmission rates based on hospitalizations with readmission rates based on population. Much more urgent is modifying the ACA readmission penalties so that a hospital that achieves an absolute decrease in readmissions is not penalized even if its per-discharge readmission rate does not change. It is hard to justify penalizing a hospital if patients are doing better and Medicare is spending less.”

Joseph G. Ouslander, MD
Professor and Senior Associate Dean for Geriatric Programs
Charles E. Schmidt College of Medicine
Professor (Courtesy), Christine E. Lynn College of Nursing
Florida Atlantic University

“The results of this project involving these 14 Medicare QIOs provide a timely example of how, through a community-based collaborative quality improvement approach, our nation can reform a dysfunctional health care system and achieve the CMS “triple aim” – improving care, improving health, and reducing costs. We will have better care and save billions of dollars over the next few decades if other communities can replicate these efforts.”

"In many areas of the country, we have a bad system of care for older people that results in poor communication, medical errors, and many unnecessary hospitalizations and related complications and costs. The community-based quality improvement approach described in this project will help us fix this situation by improving collaboration and communication among health care providers and prevent these excess hospital admissions and readmissions, and save our nation billions of dollars over the next several years.”

“This project demonstrates the ‘art of the possible’ in improving care coordination, reducing unnecessary hospitalizations and their related complications and costs. If implemented in communities across the country it will improve the health of millions of Americans and save billions of dollars at the same time.”

Uma Kotagal, MBBS, MSc
SVP Quality, Safety, and Transformation
Executive Director, James M. Anderson Center for Health Excellence
Cincinnati Children’s Hospital Medical Center
President of the Academy for Healthcare Improvement

“This paper is an outstanding example of the application of improvement science and statistical process control methods using a systemic approach to coordinate resources at the community level. I am impressed with the thoroughness and diligence exhibited throughout the study:  the use of a time series model for analysis of data allows us to see the data fully, and the control charts help us understand the statistical significance of the results. The use of QI methods to approach the problem, not from a narrow perspective but from a broad perspective, enables the "how" of the intervention to be real and relevant, enabling the evidence to be applied using "real world" approaches. The impact on the coordination of care and the improvement in the experience of families as they undergo care transitions is tangible as we seek to reduce preventable rehospitalizations. This is a prime example of the application of quality improvement principles to achieve the triple AIM: improving outcomes, reducing cost, and improving the patient experience. Congratulations!”

Susan R. Mende
Senior Program Officer
Robert Wood Johnson Foundation
Contact: Alex Levy, Media Relations

“The Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Quality initiative focuses on improving the quality of patient care by ensuring that all key stakeholders in a community – those who give care, get care and pay for care – are working together. Leveraging social capital and building a coordinated system of care between hospital and community services leads to better care, a better experience for patients, and better value overall.”

Maureen Bisognano
President and CEO
Institute for Healthcare Improvement

“This important paper highlights a new way to think about improvement. Researchers have typically described the importance of leadership and organizational culture, and the intervention itself. Brock, et al., adds a vital new ingredient to successful implementation: quality improvement methods. We know from other industries that QI has been a critical part of creating leaner processes and better outcomes. The paper highlights the need to measure data and results over time to determine the effects of specific interventions across a complex systems challenge.”

"The paper highlights a new skill needed for all clinicians and leaders going forward-the ability to look beyond the walls of a hospital or practice. As health care is reframed across the U.S. as a result of ACA, more of our work will cross traditional boundaries and require collaborations between professions and parts of the system and certainly will include patients, families and other carers to optimize the results. This work aimed for significant and important outcomes that required cooperation and new ways to measure across the continuum of care.”

“Brock et al. highlights the need to work at all levels of the health system when aiming to improve complex problems, like readmissions. The quality improvement methods at the front line of operations support and enhance policy changes and yield new ways to measure process and outcome measures over time.”

Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies

“I take away three break-through concepts from this work: first, improving care transitions and reducing rehospitalizations can be accomplished through locally customized, adapted, fluid strategies: improvement was the goal, not adherence to a protocol. Second, community-based efforts that bring together providers from across the continuum of care will identify many more opportunities to impact avoidable readmissions than simply improved discharge planning. Brock and colleagues show that when cross-continuum teams identify patient preferences, link patients to appropriate services and engage patients and families in their care and how to best navigate the health care system, fewer hospitalizations and rehospitalizations occur. Third, we may be measuring readmissions incorrectly as improvements in care across the continuum appear to impact a cycle of repeated hospital utilization.”

“This article is required reading for all hospital and cross-continuum readmissions teams across the nation. Brock and colleagues demonstrate that the approach of collaborating across settings to reduce (re)admissions is a "triple aim" strategy of reducing cost through improving care. I encourage all hospitals to form or join cross-continuum teams as part of their readmission reduction efforts.”

“The impact of the QIO project is impressive and powerful because readmissions were decreased for entire populations of Medicare beneficiaries. Many current readmission reduction strategies are targeted at small "high risk" populations that may have relatively large impacts on the target population, but nearly undetectable impacts at the population level. Health care delivery transformation will require population-wide improvements such as those demonstrated by Brock and colleagues.”



The Top 10 List: Key Findings from QIO Paper

Brock et al., “Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries”
– JAMA, Jan 23, 2013


1.    Care transitions are important for reducing rehospitalizations and hospitalizations—and avoiding medical errors that lead to suffering and reducing costs.

2.    Over the course of 3 years, quality improvement methods were used to support an array of efforts in 14 communities nationwide. There was a potential to reach nearly 800,000 Medicare beneficiaries. Funded by Centers for Medicare & Medicaid Services, and led by Quality Improvement Organizations (QIOs).

3.    It appears to have worked! Hospitalizations and rehospitalizations declined nearly twice as fast in the intervention communities as in the comparison sites. Both declined by nearly 6%, on average, over 2 years. There was no adverse effect upon patient-reported measures of satisfaction with services, mortality, or utilization of other services.

4.    Results are helping to shape and inform national efforts now underway, such as Partnership for Patients and the Community-based Care Transitions Program, as well as community projects being led by all QIOs (53 nationwide).

5.    Unlike the usual randomized clinical trial, this project relied on the plan-do-study-act QI method. Communities analyzed results along the way, and changed course to stick with interventions most likely to work.

6.    QIOs helped facilitate more coordinated efforts among providers usually fragmented—hospitals, area agencies on aging, hospices, nursing homes,  long-term care communities, and others.

7.    This may be the first time one of America’s leading medical journals has published a report anchored in QI methods. Publishing QI work represents a profound change in the openness of American medicine to learn not only what works for a patient but what works for the delivery system.

8.    Success came for many reasons, including focus on improving care for entire communities; support for relationship building; the engagement of QIOs; and its flexibility in responding to each community’s needs.

9.    In an average community of 50,000, the project would have saved Medicare more than $4 million per year in hospitalization costs, while costing less than $1 million per year.

10.    The project gave us insights as to how we measure improvements, especially that one has to look separately at rehospitalizations and hospitalizations (because the ratio may stay the same while both numerator and denominator decline!).