The Robert Wood Johnson Foundation of Princeton, N.J., the country’s largest healthcare-focused philanthropy, has undertaken a number of initiatives to improve care transitions and reduce preventable hospital readmissions.
One of the key conclusions from these initiatives, says Anne Weiss, MPP, director of the foundation's Quality/Equality Health Care Team, is that hospitals and hospitalists can't do it alone. "Hospitals are now being held financially accountable for something they can't possibly control," Weiss says, referring to whether or not the discharged patient returns to the hospital within 30 days.
The foundation has mobilized broad community coalitions through its Aligning Forces for Quality campaign, bringing together healthcare providers, purchasers, consumers, and other stakeholders to improve care transitions. One such coalition, Better Health Greater Cleveland of Ohio, announced a 10.7% reduction in avoidable hospitalizations for common cardiac conditions in 2011.
Successful care transitions also require healthcare providers to appreciate the need for patients and their families to engage in their plans for post-discharge care, Weiss says. "I have been stunned to learn the kinds of medical tasks patients and families are now expected to conduct when they go home," she adds. "I hear them say, 'Nobody told us we would have to flush IVs.'"
Through another initiative, the foundation produced an interactive map that displays the percentage of patients readmitted to hospitals within 30 days of discharge; it has supported research that found improvements in nurses' work environments helped to reduce avoidable hospital readmissions. It also has produced a "Transitions to Better Care" video contest for hospitals, as well as a national publicity campaign about these issues called "Care About Your Care."