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June 2010 Volume I, No. 6

HIN Guest Editor Jackie Lyons

Dear Healthcare Intelligence Network Client,

Tools for medication adherence can be used to improve patient care, lower healthcare costs and prevent readmissions. This week's chart shows specific tools used by healthcare organizations to measure medication adherence. We also present new data on care transitions management programs from our May survey.

When primary care isn't available, several proxy healthcare services can sometimes fill the bill for certain conditions, helping to reduce the number of avoidable emergency room visits, says Kaiser's senior manager of emergency services. In this week's podcast, she describes important steps and suggestions to reduce unnecessary ER visits.

Want to learn what your peers are doing to deliver health promotion and disease management to targeted individuals in order to reduce readmissions? Take HIN's second annual e-survey on Health Risk Assessments by June 30 — you'll receive an e-summary of programs, strategies and results from responding healthcare organizations.

Your colleague in the business of healthcare,
Jackie Lyons
Guest Editor, ReadmissionsRx

This week's ReadmissionsRx news:

Table of Contents

  1. Specialized Home Nursing Use
  2. HealthSounds Podcast
  3. Q&A: Home Visits
  4. New Chart: Tools for Medication Adherence
  5. Trends: Care Transitions in 2010
  6. PA Hospitalizations
  7. Vital Signs: HRAs

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Specialized Home Nursing Services Used After Hospital Discharge

Specialized home nursing services after hospital discharge will be employed to combat the problems of increasing ER use and re-hospitalization, according to CIGNA and CareCentrix, Inc., who have teamed up to offer the Care Transitions Program to people enrolled in a CIGNA health plan.

The Care Transitions Program was developed in conjunction with physicians and researchers who specialize in hospital discharge and transition planning. It will provide people with clinical education, resources and guidance from nurses who will monitor and support their hospital discharge, transition and recovery at home.

"Nobody wants to return to the hospital after they’ve been discharged, but without access to proper care and support at home, many people develop complications that can send them back within just a few weeks," said Dr. Scott Josephs, national medical officer for CIGNA. "Through the Care Transitions Program we’re offering with CareCentrix we hope to decrease hospital readmissions and help people have a safe recovery at home."

The program will provide support in five key areas including:

  • Identifying a caregiver and involving that person in the individual’s care;
  • Educating individuals and their caregivers about the individual’s hospital discharge plan;
  • Building awareness of the individual’s condition, signs/symptoms of the condition and what to do if the individual’s condition worsens;
  • Helping individuals manage their prescriptions and other medications;
  • Facilitating follow-up medical appointments.

The Care Transitions Program will be offered initially in Texas over the next 12 months to people enrolled in a CIGNA health plan who are identified as at-risk for hospital readmissions. The program will be extended to more people in additional locations in 2011.

According to a recent study, one in five hospital discharges is complicated by an adverse event within 30 days, often leading to emergency care or re-hospitalization.

To learn more about this program, please visit:

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HealthSounds Podcast: Reduce Preventable ER Visits

Sara Gray In this podcast, Sara Gray, senior manager of emergency services at Kaiser Foundation Health Plan of Colorado describes two important steps hospitals can take when discharging patients to keep those patients from seeking post-discharge care in the ER, and suggests a hospital-SNF partnership to reduce preventable ER visits.

To listen to this complimentary HIN podcast, please visit:

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Home Visits Benefit Complex Patients & Prevent Re-Hospitalization

Each month, a healthcare thought leader provides more insight on the challenges of reducing hospital readmissions. This week's expert is Jessica Simo, program manager with Durham Community Health Network for the Duke Division of Community Health.

Question: What particular patient profile would benefit most from a home visit and what are the factors that impact a patient’s ability to self-manage?

Response: As a general rule for the patient population that we are serving, the ones who get the most home visits that we have profiled over the years are middle-aged individuals that have at least two chronic health conditions. These are not individuals who are generally healthy that had one adverse event that has brought them to our attention. These are people that live day in and day out with chronic health problems that they struggle with managing.

At an absolute minimum, most of our patients suffer from depression due to the fact that they are living with a chronic illness, have low income and struggle to meet their basic needs, let alone the needs their chronic condition necessitates.

For many of the other patients, part of the reason why their care needs are so complex was because they also struggle with issues around substance abuse, pain management and anxiety disorder. It is a very challenging group to manage and that is why a social worker is critical to be able to identify possible problems and to make appropriate links with other community agencies that could provide mental health services.

For more information on home visits, please visit:

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New Chart: Tools That Measure Medication Adherence

Medication adherence programs can improve patient care and lower healthcare costs by more effectively managing chronic medication utilization. We wanted to see how healthcare organizations with medication adherence programs measure adherence and compliance levels in their populations.

Click here to view the chart.

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2010 Benchmarks in Care Transitions Management: Home Visits on Rise

Tighter management of transitions in care — particularly for older adults with complex acute or chronic conditions — can help to close care gaps, avoid unnecessary hospitalizations, readmissions and ER visits, reduce medication errors and raise the bar on care quality. This white paper captures the top programs and activities by 87 healthcare organizations to coordinate key care transitions in response to the second annual Healthcare Intelligence Network May 2010 Managing Care Transitions Across Sites e-survey.

To download this complimentary white paper, please visit:

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Pennsylvania’s Hospitalization Rates for Chronic Conditions Higher Than National Rates

Pennsylvania’s hospitalization rates for diabetes, asthma, chronic obstructive pulmonary disease and heart failure were higher than the national rates, according to a new report by the Pennsylvania Health Care Cost Containment Council (PHC4).

Additionally, more than 25 percent of the individual patients admitted for any one of the four conditions were readmitted to the hospital for the same condition within one year. Nearly 10 percent of these patients were readmitted more than once for the same condition.

The report found significant variations in hospitalization rates for the four conditions based on race and ethnicity. Black (non-Hispanic) residents tended to have higher rates than white (non-Hispanic) and Hispanic residents. Among Pennsylvania residents age 65 and older, approximately one in 24 white (non-Hispanic) residents were likely to be hospitalized for one of the four conditions in 2008, compared to one in 15 black (non-Hispanic) or Hispanic residents.

"Chronic conditions are a key driver of healthcare costs," said Joe Martin, executive director of PHC4. "The opportunity for positive change lies in the fact that most hospitalizations for these four conditions could have been avoided with lifestyle changes, earlier intervention and ongoing disease management."

Based on the average Medicare payment for each of these conditions, total Medicare payments for Pennsylvania hospitalizations for the four conditions in 2007 were estimated at $615 million. PHC4 estimated that if all payors paid at the Medicare rate, total payments for all hospitalizations for the four conditions would have totaled slightly more than $1 billion in 2007.

To learn more about this research, please visit:

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Survey of the Month: Health Risk Assessments

Just a few days remain to join the 107 healthcare organizations who have already taken this survey! Aggregate data from health risk assessments (HRAs) provides a roadmap for healthcare organizations to deliver health promotion and disease management interventions to targeted individuals — with the goal of improving clinical and financial outcomes. Complete our survey on HRAs by June 30 and get a FREE executive summary of the compiled results.

To take the survey, please visit:

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