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In the recent report, mentioned in the article by Jencks et al., of the lack of benefit of coordination of care in the Medicare demonstration projects, the coordination of care consisted primarily of monitoring the patient by telephone and of providing patient education.2 Although this type of disease management might be helpful for elderly people who can direct their own care, it is not surprising that it would be ineffective in a population of elderly people with multiple serious chronic illnesses and activity limitations. Counsell et al.3 found that the rate of emergency department visits and hospital admissions decreased among frail, high-risk elderly patients who received geriatric care management services.
An integrated program that provides safe transitions from acute care settings with the use of "hands-on" care management in the home can allow people with complex chronic illnesses and functional deficits to remain in the community with much less need for acute care and with an improved quality of care.
Eric C. Rackow, M.D.
SeniorBridge
New York, NY 10022
erackow{at}seniorbridge.com
References
The current system provides high-technology interventions without routinely identifying the care that is most appropriate for each patient. It also fails to place value on the management of chronic disease or on a system of coordinated care. Correcting these problems could reduce rehospitalizations and the need for index hospitalizations.
We believe that now is the time to move from studying the problem to acting on it. Since August 2008, the Quality Improvement Organizations of the Centers for Medicare and Medicaid Services (CMS) have worked in 14 states to implement the Care Transitions Program, an evidence-based initiative to help communities reduce rehospitalizations. The CMS and the Quality Improvement Organizations measure the progress of a project with the use of a claims-based system, similar to the one suggested in the article by Jencks et al. Initial project results are expected in early 2010, and the CMS expects to expand the program nationwide in August 2011.3
Barry M. Straube, M.D.
Paul E. McGann, M.D.
Michael T. Rapp, M.D., J.D.
Centers for Medicare and Medicaid Services
Baltimore, MD 21244-1850
ocsqbox{at}cms.hhs.gov
References
A notable finding in Figure 2 of the article by Jencks et al. is the sharp change in slope, between 20 and 30 days after discharge, of the dashed line that shows readmission rates. This may indicate the point at which patients were able to obtain an appointment to see their primary care physicians after their discharge from the hospital. Overall, this study shows the false economy of underpaying primary care physicians.
Richard Rohr, M.D.
Guthrie Clinic
Sayre, PA 18840
rohr_richard{at}guthrie.org
As Rohr suggests, we would have liked to examine the relationship between rehospitalization rates and the setting to which the patient was discharged, but as we noted, the coding of the discharge destination in the Medicare hospital billing data appears to be unreliable. We share his view that the availability of primary care services is a key to successful transitions, but we doubt that changes in payment policy will be sufficient to produce a major improvement. Some people feel that payment changes are a magic bullet that will solve the problem. We believe that the rapidity and magnitude of change will also depend on strong leadership, standardization of practices, transparent measurement of performance, technical assistance for providers, involvement of families as well as patients, coordinated community efforts, and modifications to the regulatory environment. Unsuccessful transitions result, in part, from a severely fragmented health care system, and major improvement demands community teamwork among those who discharge patients, those who receive them, and patients and their families. A safe transition from the hospital to the community or a nursing home requires care that centers on the patient — who moves across organizational boundaries — rather than on care that is structured by the walls surrounding each provider.
Stephen F. Jencks, M.D., M.P.H.
8 Midvale Rd.
Baltimore, MD 21210
Mark V. Williams, M.D.
Northwestern University Feinberg School of Medicine
Chicago, IL 60611
Eric A. Coleman, M.D., M.P.H.
University of Colorado at Denver
Denver, CO 80045
References
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