Health AGEnda

The Hospital Readmissions Debate: A Primer

TS_200314219-001_Hospital300In recent months, the debate over how best to reduce avoidable hospital readmissions has become a hot topic in the national media. While many are just now joining the fray, the John A. Hartford Foundation has been working on this issue for years.

Hartford grantees have developed evidence-based models that are now in the forefront of the national debate, including Eric Coleman’s Care Transitions Intervention, Mary Naylor’s Transitional Care Model, and the Society of Hospital Medicine’s Project BOOST.

It also has been a topic we have written about extensively on our Health AGEnda blog as we seek to help shape the public debate about an issue that is at the very core of real and sustainable health care reform and of critical importance to older adults.

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Putting the IT in Care TransITions


As we age we hope to remain at home and independent for as long as possible.  Most people see the health care system as an important contributor to their ability to maintain this independence. Unfortunately, as we get older we become more susceptible to harm from a lack of coordination and communication between our health care team members.  Different health care settings do not have access to the same information. This can lead to expensive duplication of services, or worse, to actual harm when one clinician doesn’t know a patient’s medical history or his or her current medications.  In short, transitions of care between health care providers and settings are fraught with risk, particularly to the health and safety of older adults.

We at the John A. Hartford Foundation have supported the development, testing, and dissemination of evidence-based approaches that improve transitions of care.  For over a decade we have invested more than $26.4 million in innovators such as Eric Coleman, Mary Naylor, Mark Williams, June Simmons and others.

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Doing Our Part, I: Glass Half Full

Last week, in the run-up to the passage of the health reform legislation, Secretary of Health and Human Services, Kathleen Sebelius, took a brief time-out from Washington politics to speak at the joint meeting of the American Society on Aging/National Council on Aging in Chicago.  In part her remarks were intended to persuade the audience of aging services professionals that the legislative proposals would be good for older adults and the nation.

Obviously she cited the coverage of the uninsured and regulation of commercial insurance companies as advantages.  But as shown in this video clip, she also talked about some of the perennial issues of concern to the Foundation around which our grantees have made such tremendous progress.  Here are some key points: Continue reading

Reducing Avoidable Readmissions

hret-coverUnnecessarily high hospital readmissions rates have recently garnered headlines and received increased scrutiny from policymakers. Reducing avoidable readmissions has long been an important focus of our grantmaking. Now that our grantees have developed proven, evidence-based models like the Transitional Care Model , the Care Transitions Intervention, and Project BOOST, we have been looking for ways to encourage hospitals to incorporate these or similar programs. We are pleased to announce that, in conjunction with the Commonwealth Fund, we supported creation of the “Health Care Leader Action Guide to Reduce Avoidable Readmissions” by the Health Research and Education Trust (HRET) of the American Hospital Association.

This free, downloadable guide outlines steps hospitals can take to reduce avoidable readmissions.  This publication aims to help hospital leadership to begin this important process, which will not only help hold down rising health care costs, but also help provide better quality care to hospital patients—the vast majority of whom are older adults.

Hartford Grantee Receives Episteme Award

mary-naylor_finalWe know that our grantees lead important efforts that are having an impact on the health of older adults.  It is particularly reaffirming when other organizations recognize their outstanding contributions. In November, Mary Naylor, RN, PhD, FAAN, Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing (a Hartford Center of Geriatric Nursing Excellence), received the prestigious Episteme Award at the annual meeting of the Honor Society of Nursing, Sigma Theta Tau International. Sponsored by the Baxter International Foundation, the Episteme Award is given annually to a nurse who has made a significant and clinically relevant contribution to nursing. The award recognized Dr. Naylor’s Transitional Care Model (TCM), which assigns a Transitional Care Nurse to chronically ill, high-risk older adults before hospital discharge to coordinate care and help prevent hospital readmissions. In clinical trials, the model has been proven effective in reducing preventable hospital readmissions for both primary and co-existing health conditions.  Additionally, among those patients rehospitalized, the time between hospital discharge and readmission increased and the total number of inpatient days decreased.  The Transitional Care Model is currently in use at the University of Pennsylvania Health System.

We congratulate Dr. Naylor, who has also been instrumental in the success of Penn’s Center of Geriatric Nursing Excellence, on this well-deserved award!

What I Am Thankful for (and What I am Decidedly Not)

Rachael Watman and her father, mother, and son

Rachael Watman and her father, mother, and son

My 70-year-old dad, Jack, is a kind, generous, loyal man whose trust in a doctor, a nurse, and a broken health care system nearly cost him his life (a few times). For 26 years, my dad was misdiagnosed with asthma by his primary care physician. He was prescribed every inhaler known and was at times prescribed more than one. My dad spent a fortune on these inhalers, but found little relief.

It was only after the 100th or so trip to his PCP to complain of asthma that the doctor suggested that a specialist take a look at his heart. The cardiologist subsequently ordered an angiogram.

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NEJM Highlights Cost Effectiveness of Care Management Programs

Are care management programs finally gaining some traction? On September 30, Dr. Thomas Bodenheimer of the University of California, San Francisco, School of Medicine, published an article in the New England Journal of Medicine praising programs that reduce the cost of caring for older adults with multiple chronic conditions.  Dr. Bodenheimer concluded that enrolling high-risk patients in care management programs can prevent costly rehospitalization and reduce Medicare spending.  Over the past decade, the John A. Hartford Foundation has supported the testing and dissemination of many proven programs, including Care Transitions, Transitional Care, Care Management Plus, and Guided Care.  We are pleased that Dr. Bodenheimer also noted the many obstacles to adoption of these money-saving programs, including lack of economic incentives for providers and a nursing shortage.

“The evidence is strong that well-designed care management can substantially reduce costs for patients with complex health needs,” Dr. Bodenheimer wrote. We couldn’t agree more. Now we need to find ways to align incentives in favor of these cost-containing, patient-friendly programs.

Nursing Workforce Solutions for the 21st Century

© Vauteck

© Vauteck

On June 12, 2009, I–along with over 200 others–attended a forum hosted by the Health Affairs journal and the AARP/Robert Wood Johnson Center to Champion Nursing in America.  The forum, “Nursing Workforce Solutions for the 21st Century Health Care: How Do We Get There?” celebrated the recent collection of papers from Health Affairs focused on “Building a High-Value Nurse Workforce.”

During a panel moderated by Susan Reinhard, Senior Vice President and Director of AARP’s Public Policy Institute, Peter Buerhaus, Director, Center for Interdisciplinary Health Workforce Studies at Vanderbilt University Medical Center, alerted us to an irony in the status of the ongoing nursing shortage. The recession is causing a “false read”; i.e., the poor economy is encouraging retired nurses to return to the workforce, making the nursing shortage look less severe. Buerhaus warned we must not let this stopgap measure make us lose sight of the need to encourage new nurses into the field.

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