Regional collaboration between health care systems using the ACC’s Hospital to Home Early Follow-up See You in 7 toolkit was “associated with reduced 30-day readmission,” according to a study published Feb. 2 in the Journal of Nursing Care Quality.

The study was led by Joy Pollard, PhD, ACNP-BC, of St. Joseph Mercy Oakland, Pontiac, MI, and looked at ten hospitals enrolled in the Southeast Michigan See You in 7 Hospital Collaborative. The Collaborative kicked off in April 2012 and focused on ensuring follow-up with a provider within seven days of discharge using the ACC’s H2H toolkit, which consisted of: 1) six process metrics; 2) a self-assessment tool to aid facilities in their improvement efforts; and 3) more than 10 resources including risk assessment tools and tip sheets that correspond to specific, practical measures that can be used to reduce hospital readmissions by improving the early follow-up process.

The authors looked at aggregate claims data for Medicare fee-for-service beneficiaries for heart failure admissions between May 1, 2011 and April 30, 2012 and May 1 2012 to March 30, 2013. Results showed that “the overall 30-day readmission rate was reduced more in the collaborating hospitals that in the noncollaborating hospitals (from 29.32 percent to 27.66 percent vs. from 27.66 percent to 26.03 percent, P=.008).”

The authors conclude that improvement in outcomes was shown due to the “structured environment that resulted in Collaborative hospitals having a method to address gaps in practice and access to educational programs on best practice, [and] an environment to share success stories, and address barriers [to] implementing the H2H toolkit.” They add that “although each of the Collaborative hospitals had various levels of resources, efforts to improve the discharge process were implemented universally.”

"The Collaborative members feel this regional project was a success on many levels,” said Pollard. “By working together as a team on a common goal, both patients and hospitals gained benefit. Using the See You in 7 toolkit provided a starting place to hone best practices, see what worked and track progress toward reducing heart failure readmissions."

Keywords: Fee-for-Service Plans, Follow-Up Studies, Heart Failure, Hospitals, Medicare, Michigan, Patient Discharge, Patient Readmission, Self-Assessment, United States

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