Medicare healthcare providers have managed to lower 30-day readmission rates and all-cause hospitalization within two years using several evidence-based quality improvement strategies, including care coordination, according to a new study.

In the study, published in the January 2013 edition of the Journal of the American Medical Association, clinicians in the participating government-supported programs “pumped up” the care coordination process in several ways. They coached patients to make them more actively involved in their own care; put in place a series of improvements in home care; and used a federal tool kit called INTERACT (Interventions to Reduce Acute Care Transfers) to help manage the status of nursing home residents and improve medication compliance.

[See also: HAI monitoring technology use lacking.] 

Among patients enrolled in these experimental programs, readmissions declined by 5.7 percent, compared to 2 percent in comparison communities that did take advantage of these care coordination resources. The study researchers estimated that in a community of 50,000 Medicare beneficiaries, Medicare could save $4 million annually on readmissions for every $1 million spent on these community interventions.

Given the demonstrated savings of using care coordination tools, many hospitals and health systems are turning to a variety of plans incorporation such tools to help reach cost-saving goals.

The Johns Hopkins Health System is creating a robust call center to reach out “to every patient who is discharged from Hopkins, and update their documentation, in Epic, for all aspects of their experience that are relevant to their long-term care,” said Johns Hopkins’ CIO Stephanie Reel.

Reel said that the goal of the health system is “to provide comprehensive documentation, and meaningful information, at one place, in the patients’ completely electronic record, so that all members of the team, past, present and future can see it.”

Care coordination tools reduce the likelihood that patients will slip through the cracks in the healthcare system, said Jacob Nguyen, executive vice president of HealthBI, the maker of a care coordination software package called HealthCollaborate.

All care coordination tools, if used properly, he said, can create the vital links between healthcare facilities that don’t always communicate as well as they should – among themselves and with their patients.

[See also: Intermountain takes on readmissions.]