[Background Music] DIANE: When we first started to work on readmissions about three years
ago, we really didn't understand the problem at all.
We thought it would be simple to fix.
JENNIFER: We’ve realized that there are so many pieces of the puzzle that need to
be put together to make sure that a patient has a safe transition once they leave the
hospital.
JULIE: One of the biggest challenges providers face in avoiding readmissions is that they're
working in a domain of unbelievable complexity.
CHERYL: I mean, we provide so much information to the patients.
It's hard for a young, healthy patient to get it all, let alone an elderly patient who's
sick, and they just want to go home.
BRUCE: I think this kind of work has required folks to actually have new partnerships, new
collaborations, and make new friends, to be honest with you, because your goals are the
same.
JENNIFER: Providers - like hospitals, nursing homes, home health agencies, hospice, assisted
living, community-based organizations - all of these organizations need to work with the
patients to ensure that they have a smooth transition.
They all need to communicate together to ensure that a patient doesn't go back to the hospital
inappropriately.
DIANE: The best practices we've seen are for IPAs and medical groups to create teams where
they can see the patient very quickly as they're exiting the hospital – they can spend enough
time with them to make sure they understand their medications, understand how they can
take care of themselves.
SARAH: I never realized that working as a nurse practitioner with other nurse practitioners,
I was missing the value added and the different perspectives that disciplines like social
work and pharmacy can add.
JANE: Getting these cross-continuum teams comprised of medical providers from different
segments of the care continuum was really powerful, but it got even more powerful when
we engaged community services and community support organizations, as well.
DIANE: It's really once you get that entire view of the care continuum from the patient's
view, can you really begin to make a difference.
BRUCE: I like that, you know, the ant program, where the ant just takes one little piece
of sand and moves it in the ant farm, until after a day or so they've actually made a
big tunnel in the ant farm.
That's, kind of, what communities need to do.
Don't chew off too much – take a little bit at a time and be persistent.
And the payoff is tremendous!
JANE: And there's a lot of tools out there, but I tell you, there's no substitute for
just getting people in the room to express a mutual intention to work together on this
issue.
RICKI: I think that with the multiple priorities that we have in the hospitals today our most
important priorities are really about our patients.
JULIA: I think the role of patients and families is huge in preventing readmissions.
I think that education is the main way that we're going to accomplish that.
JULIE: Our patients trust and depend upon us for their care.
And our patients are not passive recipients of healthcare.
They are active parts of the healthcare system.
JENNIFER: California has achieved tremendous progress in reducing readmissions.
And if you look at the population-based measure, readmissions per thousand, from calendar year
2010 to 2012, California has achieved approximately nine to ten percent relative improvement in
reducing readmissions.
And that translates into 16,200 averted readmissions.
So if you look at the average cost of a readmission in California, it's $15,000.
So if you multiply $15,000 by 16,200 averted readmissions, we have saved Medicare $243,000,000.
JULIE: This ability to really impact people's lives in a meaningful way has never been greater,
and it's the environment that we're working in now.
So it's exciting!
[Background Music Fades]