CMS recently identified the 32 participants in its Accountable Health Communities Model, a five-year program designed to test the effectiveness of managing non-clinical health determinants of Medicare and Medicaid populations in order to improve outcomes and lower costs. The model is based upon the theory that social factors like stable housing and food security can be just as critical to reducing unnecessary utilization, such as avoidable readmissions, as strong discharge and post-acute monitoring procedures. Given the high proportion of overall health spending attributable to the elderly and other vulnerable communities, these groups have been a major focus of policymakers and health researchers. A growing body of evidence suggests that meeting non-clinical needs should be part of any population health management or readmissions reduction effort.
While efforts to look beyond the clinical setting to improve outcomes are relatively new, determinants of poor health and risk of readmission have already been studied extensively. Many factors are directly health related, such as the presence of multiple chronic conditions and specific clinical ailments such as cancer or depression, but others lie in the economic or demographic categories. According to a review of medical literature, they include low health literacy, limited social contact, and lower socioeconomic status, all of which can exacerbate health risks. For example, health illiteracy may lead a patient to take their medication improperly, while a person who lives alone can be less likely to adhere to restrictive dietary or activity guidelines without anyone else to provide support. Poorer patients may have difficulty meeting medication co-pays and may choose to go without or take a lower dosage to prolong their prescriptions, which may worsen their condition.
Some socioeconomic factors are easier to accommodate than others. One recent study published in the Journal of the American Geriatrics Society found that incorporating unpaid caregivers like spouses or family members in the discharge process can significantly reduce avoidable readmissions as well as overall care costs. Analyzing existing literature, the study found informal caregivers were able to reduce the likelihood of 90-day and 180-day hospital readmission by 25 percent and 24 percent, respectively. With some training, caregivers handled more complex aspects of patient management, such as wound care, medication adherence, and operation of specialized medical equipment. In addition, when patients were re-hospitalized, the length of stay was usually shorter, and the cost of post-discharge interventions tended to be lower.
Top 10 Hospitals with Highest Readmission Rate
|Hospital||Readmission Rate||Case Mix||CC/MCC Rate|
|NYC Health and Hospitals/Lincoln||19.4%||1.28||40%|
|NYC Health and Hospitals/Queens||19.4%||1.29||46%|
|DMC Sinai Grace Hospital||19.0%||1.43||54%|
|Harlan ARH Hospital||18.9%||1.10||45%|
|Kingsbrook Jewish Medical Center||18.9%||1.64||53%|
|St John’s Episcopal Hospital South Shore||18.9%||1.53||51%|
|Aventura Hospital & Medical Center||18.8%||1.51||51%|
|Henry Ford Hospital||18.7%||2.08||64%|
|Florida Hospital Orlando||18.7%||1.75||58%|
|All Hospital Average||15.6%||1.39||50%|
Source: Definitive Healthcare
Physical and cognitive disabilities can also make it more difficult for patients to properly care for themselves after discharge. While skilled nursing facilities usually provide sufficient health monitoring and customized daily care, one pilot project at a nursing home chain suggested that directly integrating clinical treatment into the homes themselves could reduce readmissions and inpatient utilization. Juniper Communities, a for-profit chain operating out of New Jersey, hired a provider organization to offer primary care, laboratory, pharmacy, and therapy services onsite at its facilities and participate in discharge planning. The program relied on Junipers’ EHR system, which kept track of patient conditions and helped connect them with appropriate providers. Compared to other Medicare beneficiaries, the Juniper population had half the inpatient hospitalization rate, 80 percent lower readmissions, and a 15 percent lower rate of ED use in the first year. However, the strategy may not be feasible at most SNFs due to the high capital investment required.
Despite the promising evidence, large-scale efforts are still moving slowly. The Accountable Health Communities Model is intended as a demonstration program only, with two main tracks. 12 of the participants selected the Assistance track, under which providers will refer patients to appropriate organizations, and the other 20 picked the Alignment track, in which they will also collaborate with community organizations to identify gaps in care. The CMS grant funding only covers screening, patient navigation, and alignment efforts, and cannot be used to support direct patient care or assistance. Essentially, any improvement in the population is limited to the capacity of existing community organizations, assuming they are utilized effectively. In addition, the program lasts five years, so it is unlikely that CMS will finance any other similar initiative before it is completed and the results are analyzed. In the meantime, it will be up to private organizations to finance and manage community health initiatives targeting patients’ unmet social needs.
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