This special edition of Spotlight explores AF4Q's endeavor to reduce preventable hospital readmissions and improve the quality of care delivered across care settings.

This special edition of Spotlight explores AF4Q's endeavor to reduce preventable hospital readmissions and improve the quality of care delivered across care settings.

When patients move across settings, for example, from a hospital to a nursing home, they are particularly vulnerable. Lapses in care, miscommunication of information between providers, and mixups with medication are all possible side effects of “handoffs” that are not well coordinated. Poor care coordination frequently results in unnessesary and costly hospital readmissions. The United States health care system has long struggled with this issue; ultimately it costs the system $17 billion per year.

Recognizing the importance of this issue, the Robert Wood Johnson Foundation has elevated the national conversation in the month of February through its Care About Your Care campaign. The campaign focuses on improving care transitions to reduce avoidable hospital readmissions and on how nurses, care coordinators, doctors, consumers, caregivers, and patients can work together to accomplish this.

AF4Q Alliances have done significant work to improve the quality of care in hospital settings and are expanding these efforts to improve care across settings.

As part of Aligning Forces for Quality, hospitals, ambulatory care providers, community health centers, and other state and local agencies are working together to improve quality and reduce costly hospital readmissions. Most of the AF4Q Alliances have embraced public reporting of readmission rates as one of their key strategies for addressing quality, cost, and efficiency and, in doing so, are learning many lessons and experimenting with different approaches.

Common Strategies for Reducing Hospital Readmissions in AF4Q Communities

• Care coaches for patients with a high likelihood of readmission.
• In-home visits following hospitalization by nurses and other professionals to ensure appropriate follow-up and medication adherence.
• Use of risk-stratifying tools to identify patients with a high likelihood of readmission.
• Use of patient educational materials adapted to appropriate literacy levels.
• Payment reforms to incentivize providers to reduce readmissions.
• Use of standardized discharge care planning.

The AF4Q Hospital Quality Network connected more than 100 forward-thinking hospitals across the 16 AF4Q communities to collaborate to improve quality and safety of patient care.

Participating AF4Q hospitals collectively avoided hundreds of readmissions; improved patient safety for patients with limited proficiency in English, standardized the way the hospitals collect information on patients’ race, ethnicity, and language preferences; and ensured more patients received timely care. Ninety percent of hospital teams improved the quality of care for their patients in measurable ways.

Over the 18 months of this AF4Q collaborative, hospital teams conducted many small tests of change and implemented strategies to reduce variation in performance measures. Ideas for improvements and process changes came from members of hospital teams and also from the large network of participating teams. 

Participating hospitals worked to decrease 30-day readmission rates following heart failure hospitalization and ensure that heart failure patients received all recommended care. 

Key findings include:

• Seventy-seven hospital teams in 15 AF4Q communities across the country targeted reducing readmissions as a quality improvement priority.
• Sixty percent of these hospitals reduced readmissions for heart failure patients.
• Teams avoided approximately 486 readmissions within 30 days of hospital discharge. 
• Fifty-eight hospital teams improved in their adherence to all components in the Measure of Ideal Care (MIC), and as a result 18,311 heart failure patients received all four measures of ideal care.