The hope of health reform is to increase access to care, while simultaneously paying for those newly covered people by squeezing waste and inefficiency out of the system. This is easy to say but hard to do, particularly without raising fears of further reducing the rather mediocre quality of care we currently provide.

It is possible, however, and the Foundation is very proud to have facilitated the identification of some of that inefficiency where costs can be lowered and quality of care can also be improved. A few years ago, Foundation grantees Eric Coleman and Mark Williams met at a Foundation meeting on dissemination of innovation. They found they shared an interest in the hospital readmission data that retired CMS staffer Steve Jencks had been sharing at meetings. Jencks, Coleman, and Williams teamed up, publishing their analysis of Medicare hospital readmissions data in the April 2, 2009 issue of the New England Journal of Medicine.

The paper garnered extensive media coverage and made policymakers aware of readmissions among Medicare patients. The main finding was that 19.6% of Medicare beneficiaries are rehospitalized within 30 days of a hospital discharge.

Some readers might argue, "What do you expect? They are sick!" However, Jencks et al. found an additional, highly disturbing statistic: about half of hospitalized Medicare patients return to the hospital without having seen a physician while they were released. This is a perfect example of high-cost, low-quality care just begging for improvement. Here’s why:

1) If patients are sick, then scheduling a quick visit with a primary care or appropriate specialist visit post hospital discharge is all the more important.
2) There is enormous variation from state to state and hospital to hospital on readmission rates.
3) We know that interventions like Eric Coleman’s own Care Transitions Intervention and Mary Naylor’s Transitional Care Model reduce readmissions, save total costs, and improve patients lives. It's just that none of these things have been public-policy priorities until now.

While we’ve been waiting for the payment incentives and public demand for quality to catch up, we’ve also been supporting BOOST (Better Outcomes for Older adults through Safe Transitions). In this special dissemination effort, the Society of Hospital Medicine (SHM), has Foundation funding to spread BOOST, a menu of steps (or a “bundle” in the Institute for Healthcare Improvement's terms) to improve discharges and reduce readmissions. Hospitalists are physicians who work solely in hospitals along with nurses and social workers (and all the other professionals) to meet the needs of hospitalized patients. As a large and growing professional association, SHM can play a leadership role in improving care of their older patients as part of their professional responsibilities.

The BOOST bundle takes some of the best ideas of evidence-based practice for reducing readmission and spreads them across the health care team. The practices include assessing patient readiness for discharge, educating patient and family caregivers, carefully reviewing medication, and scheduling follow-up appointments. In the video below you can see a nurse from Piedmont Hospital in Atlanta making a planned BOOST follow-up phone call to a recently discharged patient, reviewing major concerns such as understanding of the care plan, access to medicines, and follow-up appointments.

BOOST is not rocket science, just a bundle of very important—and often simple--things that all too often don't get done. We are very hopeful that the incentives of health payment reform will make the audience for this exciting program grow wildly, as it needs to do.