Reducing Hospital Readmissions Statewide: Q&A With Crystal Berumen of Colorado Hospital Association

In August, UnitedHealthcare announced it was providing a $1.1 million grant to the Colorado Hospital Association to help hospitals in the state implement a program to reduce avoidable hospital readmissions. The grant goes to the Reducing Hospital Readmissions and Safe Transitions Collaborative, a two-year program aimed at helping participating hospitals implement a patient-centered process for discharge planning and discharge education.


Crystal Berumen, vice president of patient safety and health system integration for CHA, discusses why CHA is basing its program on improvement measures from Boston University School of Medicine's Project RED (Re-Engineered Discharge) and what CHA hopes to achieve in the program's two years.

Q: How did CHA learn about the Project RED intervention?


Crystal Berumen: Reducing avoidable readmissions and improving care transmissions have been hot topics in the hospital community for the past few years. There are a lot of different approaches and methodologies to address these issues, even some models that originated in Colorado. I did my research in terms of trying to explore different models we could use here.


One of the most useful tools I came across is the "Health Care Leader Action Guide to Reduce Readmissions," a compendium put out by the Health Education Research Trust that was [assembled] in Jan. 2010. Essentially what they did was an inventory of all of the major readmission and care transition projects currently going on around the country, and then analyzed each in terms of efficacy — what payor sources did they reach, what were the different methods used, was it more of an inpatient focus vs. outpatient focus, and other parameters.


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Then they determined if the projects met major strategies in three major buckets: things to be done during hospitalization, at the point of discharge and post-discharge. These major strategies were largely used to determine efficacy and demonstration of strong evidence for reducing avoidable readmissions. Project RED was among the top four projects as an intervention that had very strong evidence of reducing avoidable readmissions.


Q: What made Project RED stand out versus the other three projects in the top four?


CB: One of the reasons I specifically narrowed in on Project RED was it was the only model that had a strong inpatient focus as well as activity in the outpatient setting. The other three had more of a transition of care focus, which means they were really focused on the outpatient setting and had little or no engagement with the hospital. Of the four projects identified as having strong evidence for reducing avoidable readmissions, it was also the only one that demonstrated strong efficacy for all types of patients, including those that are young or elderly, covered by Medicaid, Medicare or by private payor. That may not seem like it's important, but many of the readmissions projects out there have really only been piloted on the Medicare population, whose needs are likely completely different than an individual or family that's insured by a private insurer, or someone who doesn't have insurance.


That's one of the main reasons we chose that model — it has such strong evidence in the inpatient setting, but could be applied to a wide variety of different types of hospitals and patients. As a hospital association, we have to be very conscious that we are meeting the needs of our diverse membership, from big, private urban hospitals to smaller, rural critical-access hospitals. We had to find a model that could be adapted to each type of hospital and their unique community and patient population.


Q: The Project RED intervention features 11 components. How closely is CHA following these steps?


CB: Project RED serves as the foundation for phase one of our program, which is the inpatient focus-side of the project. Phase two will focus more on the care transitions or community aspects. Project RED really does serve as the foundation, the model, for the inpatient phase. Hospitals can adapt it, make changes or add on to it as necessary and they will probably find, depending on the different hospitals participating in the project, that they will need to do that.


But we are going beyond the original Project RED scope. We have 24 hospitals participating [in the collaborative], and we held the kickoff in August. For the next 24 months, we will be working with those hospitals one on one to implement the various elements of the project.


With Project RED and its 11 steps, there actually is not really any magic to them. They are steps hospitals were likely doing already, it's just that in most cases they were very fragmented. Project RED bundles everything and builds a little more accountability into the process. It makes sure a hospital team as a whole is looking at those 11 steps and making sure they're all being done in a fluid format. Before, for example, patients were likely getting their meds reconciled and getting a follow-up phone call, but the right hand and left hand didn't necessarily know what the other was doing — versus with this approach, it is bundled and there's a team that's overseeing and having accountability for all 11 of those elements.


Q: Can you further explain this bundled/team approach?


CB: Before, all of those 11 [components] were supposed to be everybody's responsibility — but as it goes with vague accountability, because it is supposed to be everyone's responsibility, everyone assumes that someone else is taking care of the various steps and therefore it really fails to become anyone's responsibility. In this approach you put together a team and those 11 steps are divided up within the team. While the team will look different from one hospital to another, through this approach, at the end of day, before a patient is discharged, there will be a run-through of all of those different steps to make sure everything is occurring succinctly and sequentially. It's taking all of those different steps and now making sure they're all occurring every single time with every single patient.


Q: What do you hope to accomplish during the two years of this program?


CB: Our goals with this project are to spread the Project RED model or an adapted version within hospitals. It's likely to be adapted in each individual hospital. Right now they're all piloting it in one target population or target unit. The goal two years from now is to have that to be spread further within a given hospital. For a big hospital, maybe it is spread to three to four more units, versus for a smaller, critical access hospital, maybe it will be spread hospital-wide.


We definitely want to see a spread of the model throughout the hospital because we're going to be collecting some process measures on those 11 steps. We want to see all of those elements being done every single time, at least within those units or pilot target population. We also want to see more partnerships and communication, not only within the facility but also in the community. Depending on the target population, maybe hospitals will start working more collaboratively with their nursing home, skilled nursing facility or behavioral health facility, for example.


Ultimately, we want to see the percentage of avoidable readmissions go down. The challenge we face in Colorado is we already have a smaller percentage of avoidable readmissions compared to the rest of the country. But we still want to see our numbers drop; since they're avoidable readmissions, they shouldn't be coming back to the hospital for the same reason.


Q: What are your feelings on partnering with a private payor on this program?


CB: The fact that UnitedHealthcare provided financial assistance by way of a grant is really a testament to their desire to pilot some evidence-based tactics to help avoid readmissions. It's an unusual partnership, but they really are interested in testing some of these things to see if they can roll them out nationwide, across their entire system.


Learn more about the Colorado Hospital Association.

Related Articles on Readmissions:

Dartmouth Report Shows Little Change in Readmission Rates From 2004-2009

AHA Report Questions Link Between Admissions, Quality

Canadian Study: Hospital Readmission Rates Not Accurate Measure of Care Quality

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