Hospitals and Primary Care Physicians Partnering on Care Transitions: Lessons from a Statewide Multi‐Site Learning Collaborative

Background:

Optimizing hospital care transitions continues to be a quality improvement focus for hospitals and hospitalists. As accountability for patient outcomes spreads beyond hospital walls, collaborative partnerships between hospital and community based providers are increasingly important to transition patients safely and effectively from hospital to home and sub‐acute care settings. The Michigan Transitions of Care Collaborative (M‐TC²) is a mentor‐guided learning collaborative that helps physician organizations (POs) and their local hospital partners improve gaps in care transitions from the hospital.

Purpose:

Utilize a state‐wide quality collaborative to help POs and hospitals improve processes and coordination of care for patients discharged from the hospital.

Description:

The M‐TC² improvement strategy is structured similar to SHM’s Mentored Implementation model. Eight mentors are currently working with 18 PO‐hospital teams across the state. Each team submits data to a quality management center for analysis and discussion at our tri‐annual collaborative wide meetings. To enhance collaborative practices between hospitals and POs, we worked with sites to coach them on best practices in care transitions as outlined in the SHM’s BOOST program, and helped facilitate process improvement changes focused on transmitting discharge summaries within 72 hours to Primary Care Physicians (PCPs), and seeing patients in the PCP office within 7 days of discharge. The rate of transmitting a discharge summary to the PCP office within 72 hours discharge improved to 76% compared to 58%, one year prior. Patients seen in the PCP office within 7 days of discharge did not significantly change (45%, compared to 42% from a year prior). Throughout the collaborative, a positive response to the Hospital Consumer Assessment of Healthcare Providers and Systems(HCAHPS) question regarding “patients were provided information about whether they would have the help needed after leaving the hospital” increased to 86%, compared to a baseline rate of 78%. Although a few of the hospitals reported a trend toward reductions in their readmission rates, this pattern was not observed in all sites. The overall 30 day readmission rate across all 18 PO‐hospital teams did not significantly change over a one year period.

Conclusions:

The M‐TC² program facilitated collaboration between physician organizations and hospitals which led to improved timeliness of transmission of discharge summaries and was associated with improved patient perception of discharge preparedness. While some hospitals’ intervention units experienced improved readmission rates, the overall rate for all participating hospitals was unchanged. Additional interventions targeting other key aspects of the care transition and engaging other partners in improvement efforts (such as skilled nursing facilities and other patient support networks) will likely be necessary to move the needle on hospital readmission rates.