Erika Linnander, GHLI Senior Technical Officer
Unplanned hospital readmissions are estimated to cost more than $17 billion each year for Medicare alone. Across the country, hospital executives, clinicians, policymakers, and researchers search for the best ways to reduce unplanned hospital readmissions. Hospitals are intently focused on this issue, and are joining quality improvement networks and programs to guide their efforts. A dizzying array of tools and best practices are available, but which approaches are in fact tied to reduced readmission rates?
Researchers at Yale’s Global Health Leadership Institute continue to study which strategies work best for providing quality patient care and reducing hospital readmissions. Between 2010 and 2012, they found significant increases in the use of nine frequently recommended strategies among hospitals participating in the State Action on Avoidable Rehospitalization initiative or the Hospital-to-Home Campaign.
The latest evidence appearing in the May 2015 issue of the Journal of Internal Medicine shows that hospitals that incorporated any combination of three or more of these strategies which focused on changes to hospital culture and administration, saw significantly larger reductions in risk-standardized readmission than those hospitals that took up fewer strategies. After adjusting for hospital size and location, hospitals that implemented several strategies reduced their readmissions rates by 0.4 percentage points more than hospitals that implemented fewer strategies. Scaled nationally, this improvement could save the Medicare $400 million annually.
The study findings showed rather than a single recipe, many different combinations of strategies led to similar reductions in readmission rates.
What can health care professionals make of these results? First, there is no silver bullet. None of the nine strategies alone accounted for sizable reductions in readmission rates. Second, the successful hospitals were implementing at least three new strategies to reduce readmissions. Because readmissions have multiple root causes, a bundle of strategies is likely needed. Different hospitals used different means for achieving results. Last, change is hard. Despite their enrollment in major quality improvement initiatives, 70% of the hospitals surveyed had taken up fewer than three strategies during the course of the study.
|Photo Credit: Thi Nhat Le|
Zahirah McNatt, GHLI Director, Leadership Education and Practice
As part of the Senior Leadership Program (SLP), I recently worked with delegates from Cambodia, Laos, Myanmar, Philippines, and Viet Nam in Phnom Penh, Cambodia to address strengthening the enabling environments for persons with disabilities. Each team brought with them a national problem – high staff turnover, too few rehabilitation professionals, poor access to physical rehabilitation centers and limited knowledge among people with disabilities about their legal rights.
For this program, all written materials were translated into four languages and we had simultaneous interpretation during lectures and group activities. For five days, we explored problem solving, leadership and management, good governance and the United Nations Convention on the Rights of People with Disabilities (UNCRPD).
The trip was an awe-inspiring opportunity to encourage collaboration among several stakeholders. We had representatives from national disabled people’s organizations, government ministries, parents, teachers and physical rehabilitation facilities. The diversity created dynamic teams and allowed for cross-country dialogue about better integrating disability rights efforts in Southeast Asia.
The SLP created a safe space for discussion on how to operationalize the aspirations of the UNCRPD. Many countries stall once ratifying such agreements and are unable to make the dreams reality. These five nations have the potential to implement practical solutions that increase accessibility and diminish discrimination against people with disabilities.
While there are many difficult stories about children who use wheelchairs being unable to get to school or people with visual impairment being denied the right to vote – I remain hopeful. I am personally motivated by the role models present in the Program itself – women and men with and without disabilities who have chosen to champion the rights of others. I left Phnom Penh struck by the power of our unified voices and further committed to encouraging and demanding justice and equality for all.
|Heather Fosburgh and Dayna Keene, YSPH Professor|
Heather Fosburgh, GHLI Program Manager
It’s still hard to believe that in the course of seven weeks, the GHLI Leadership Saves Lives team has travelled to ten hospitals in ten different states to conduct more than 150 interviews to learn more about the cardiac care process in each of the hospitals.
I had the opportunity to participate in interviews and observations at three hospitals in Arizona, Illinois and Florida. Each hospital, like its geographic location, was unique … as were the people. However, interwoven in these differences, were common threads of excitement and eagerness to find new ways to improve patient care. Whether it was a nurse, a physician or an information technology specialist, hospital staff and faculty were truly interested in how they could help make a difference. It was inspiring to see their passion and motivation.
Conducting these interviews for the LSL program provided me a brief but up-close glimpse into how things are behind the scenes of hospital patient care and management. We spoke with more than a dozen staff members at each hospital who shared, stories, experiences, and honest feelings with us.
We have six months before the next round of hospital site visits start and during that time, we will be busy reading and analyzing the information collected to date. I find it fascinating to know that taking these individual experiences and combining them all together will contribute to a body of research that strives to understand what aspects of organizational culture can help improve mortality rates for patients with heart attacks.
Although it was less than two months work for me, I remain impressed by how much coordination it takes to effectively care for a patient who suffers from a heart attack coupled with the dedication of the people who provide this care.
Lea Hamner, 2014 GHLI Fellow
Over the past few months, I have travelled to five counties across the US to better understand why certain regions in a state have lower obesity rates than similar counties in the rest of their state. I work with a team of GHLI researchers who seek common themes across these counties in order to examine what may be replicated elsewhere to foster a community of health and reduce obesity rates. Some of these counties seem like an obvious pick to me—an urban setting, a progressive culture, an abundance of outdoor activities. Yet, we also encountered some tiny rural counties in the middle of nowhere that somehow seem to be doing things right.
Leslie Curry, Ph.D., GHLI researcher
Many efforts have been directed at strengthening rural primary care services for women and children in low-income settings. But few studies have examined the sustainability of these programs or the potential long- term impact of these interventions on the mortality of women and children.
Researchers at the Yale Global Health Leadership Institute (GHLI) evaluated the impact of the Ethiopian Millennium Rural Initiative (EMRI) in terms of lives and money saved. EMRI was a systems-based intervention to improve the performance of 30 primary health care units each servicing 40,000 people living in rural areas of Ethiopia. Their findings are published in the November 18, 2013 issue of the Public Library of Science journal.
“We found multiple areas of this program were impacted — including the health system infrastructure, human resource capacity and utilization of HIV treatment services,” explains Leslie Curry, Ph.D., GHLI researcher and paper co-author. “Most notably, we discovered impressive cost-effectiveness in terms of lives saved over five years of follow up. The study found that initial investments in critical areas such as access to water and electricity and improvements to buildings, provide far-reaching benefits for health care delivery in rural settings. The program also expanded care and treatment services for HIV patients. In addition, investments in system-wide improvements (such as supply chains and laboratories) were shown to noticeably strengthen the capacity of the rural health care system. If this model is scaled up, the four major regions of Ethiopia could save nearly 35,000 lives.
“This large project not only implemented and evaluated a program to improve rural health care across several sectors,” explains Curry, “it also required developing leadership capacity all across the health care system.” The researchers hope these results will be used in Ethiopia as they continue with their plans to improve primary care systems nationally.
The analysis underscores the particular importance of sustained performance in driving cost effectiveness. Although the pay back in terms of lives saved did not translate to cost savings in the first 18 months, within five years of sustained performance, the benefits far outweigh the costs of the program.
The researchers hope these results will be used in Ethiopia as they continue with their plans to improve primary care systems nationally.
|GHLI staff met with personnel at Coca-Cola Kwanza
as part of a new public-private partnership.
Kristina Talbert-Slagle, PhD,
Associate Research Scientist, GHLI
Our GHLI team recently traveled to Dar es Salaam, Tanzania to conduct interviews on progress made in a partnership between The Coca-Cola Company and the Medical Stores Department (MSD) in Tanzania. The goal of this public/private joining is to transfer expertise from The Coca-Cola Company to MSD on how to deliver products in hard-to-reach areas, in order to improve access to medicines throughout Tanzania.
On our first day, we interviewed local bottlers from Coca-Cola Kwanza to learn more about how they share their knowledge of product delivery with MSD. Particularly striking to me was the level of commitment to the project from these individuals, who told us touching stories about the work they had done with their fellows at MSD, how motivated they felt to improve access to medicines in Tanzania, and how happy they were to give their personal and professional time to this project.
One person told us how, growing up in Uganda, he had watched people die from lack of medicine, and so he understood on a deeply personal level the importance of this project, and he was committed to giving it whatever time and energy it took in order to help save lives.
We also interviewed staff members at MSD to hear their perspectives on changes that have resulted from this partnership. We came away excited about all the good work and good ideas that have been put in place in the most recent phase of this ongoing collaboration.
I later visited an MSD warehouse to witness piloting of a route for medical delivery that was developed using new network optimization software and the process to get materials distributed. I also got a firsthand look at what challenges remain in implementing network optimization, such as incorrect GPS codes and extremely slow data processing software.
We came away from Tanzania inspired by the good work that has been done in improving delivery of medicines, and we look forward to sharing our findings in our research publications and online case over the coming months.