Care transitions – when patients move from one care setting to another – mark perilous points in patient care. As many as 20 percent of Medicare beneficiaries need to be readmitted to the hospital within 30 days of discharge, often due to complications associated with transitions or support in the community. With healthcare reform, hospitals that do not reduce avoidable 30-day readmissions face Medicare financial penalties. In addition, physicians and certain community-based organizations are incentivized to improve practices.

[See also: CMS to pay $2.3M for help reducing hospital readmissions.]

"This work focused on every aspect of hospital discharges for all Medicare beneficiaries in a geographic area, and brought providers together to confront their problems and offer evidence-based care transition support," said Joanne Lynn, MD, director of Altarum Institute’s Center for Elder Care and Advanced Illness, and corresponding author for the JAMA article, said in the news release. "Care transition professionals confronted the often-unnoticed effects of errors between settings and were motivated by the unnecessary suffering of their patients, clients, and families to improve overall care."

In addition to the statistics revealing better community care, this paper also marks what may be the first time that JAMA has published a project using quality improvement (QI) methods to measure and report outcomes, including process control charts. This approach is a substantial difference from the formality and context-blind nature of a randomized clinical trial. With the QI approach, participants focus on the system and aim for improvements with ongoing monitoring, rather than setting up a research project to test 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 also what works for the delivery system.

Efforts to build on this work are already under way, such as the Partnership for Patients, the Community-based Care Transitions Program, and coalition-based care transitions work led by QIOs in every state, the authors noted. New federal rules allow physicians to bill Medicare for certain care coordination activities, and hospital penalties for high readmissions rates will escalate over the next two years. The community-based approach to addressing readmissions offers a new way of thinking about how to affect positive change, they added.

"This has far reaching implications for the future of health care at any level," said Brock. "When a community works together to improve care at the system level, everyone involved will see the positive effects."