Stephen F. Jencks, MD, MPH
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2383.
Corresponding Author: Stephen F. Jencks, MD, MPH, 8 Midvale Road, Baltimore, MD 21210; e-mail, firstname.lastname@example.org.
Jencks S.; Defragmenting Care. Ann Intern Med. 2010;153:757-758. doi: 10.7326/0003-4819-153-11-201012070-00010
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Published: Ann Intern Med. 2010;153(11):757-758.
Rehospitalizations that occur soon after hospital discharge are drawing increasing attention. About 2.5 million Medicare beneficiaries and about 2 million other patients are rehospitalized within 30 days of discharge, with total hospital costs (not including physician services) of about $44 billion (1; Steiner C, Jiang J. Personal communication). From the perspectives of payers, purchasers, and policymakers, avoidable rehospitalizations represent massive and remediable waste. However, most rehospitalization is the result of clinical deterioration, occurs emergently, and is often necessary by the time the patient reaches the emergency department. Some emergency department visits might be prevented from turning into hospitalizations. However, compelling evidence from a series of controlled studies (2–4), in which interventions to improve the transition from hospital to posthospital care have reduced rehospitalizations by 30% to 50%, suggests that the rehospitalization problem represents a failure of those transitions rather than willful overuse of hospital services. It is a symptom of fragmented care.
Victor L Kovner MD FACP
December 7, 2010
Defragmentation Repair by Home Health Palliative Care
Home visits by skilled nurses and physicians prevent re- hospitalization by increasing compliance with diet, activity and medication. This is hospice for the non-dying. It costs less than a night in the Emergency Department and decreases the days in ICU at the end of life. Home palliative care improves continuity, communication and compassion; the three missing ingredients in today's high tech care.
Group Health Cooperative
January 30, 2011
Group Health and Defragmenting Care
January 24, 2011
To the Editor:
We at Group Health Cooperative in Seattle, Washington read with interest the article by Kind et al and Dr. Stephen F. Jencks' editorial on "Defragmenting Care" in the December 7, 2010 issue. Group Health is a consumer-governed health system providing coverage and care to 650,000 members in Washington state and Idaho. About two-thirds of our members receive care in our integrated delivery system (Group Health Physicians and Clinics) and one-third receives care through our contracted network of 7000 providers. The majority of acute care hospitalizations for all of our members occur in seven preferred community hospitals where Group Health physician hospitalists and care management nurses practice.
Despite our advantages toward defragmenting care, we realized in early 2009 that our emergency department, acute inpatient hospitalization and readmission rates--although in the top 10% of our benchmark comparisons--were not breakthrough. For example, our Medicare 30-day readmission rate was nearly 16%. Therefore, we began a journey to achieve even greater integration through the application of a Lean management system. The key components of this new initiative, which we called the Emergency Department and Hospital Inpatient (EDHI) program, are not unlike the recommendations Dr. Jencks cited in his editorial:
1) We provide Dr. Coleman's four-pillar teaching in a standardized way for all patients at high risk of readmission, including ensuring provider follow-up within 7-10 days of hospitalization; nurse calls to reconfirm patients' "My Home Plan" within 48 hours; and pharmacist- performed medication reconciliation.
2) Hospitalized patients requiring care at a skilled nursing facility (SNF) receive standardized transition management into and out of the SNF according to same principles.
3) Hospitalists, in conjunction with a 24-hour physician and health plan nurse team, identify those members presenting to emergency departments who would benefit from alternative placement or home-health follow-up versus inpatient admission or readmission.
4) Patients meeting key criteria are provided hospitalist-led, shared decision-making around end-of-life issues.
Our results have been impressive: Since inception of the program in late 2009, Medicare admission rates have decreased by 6.5% and readmission rates have dropped to 14% (our goal is 10%). Patient satisfaction with care by inpatient providers has risen 30 percentile points in three of our preferred hospitals. Estimated savings from this initiative, along with our Medical Home initiative , have resulted in a 10% decrease in hospital- associated clinical costs Four of our preferred hospitals have adapted our EDHI program for their other health plan and Medicare patients. We concur with Dr. Jencks that defragmentation can be accelerated, even in integrated systems--and it can be contagious.
Brenda Bruns, M.D. Executive Medical Director Group Health
Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-43.
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