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The American Journal of Managed Care July 2018
Differences in Spending on Provider-Administered Chemotherapy by Site of Care in Medicare
Yamini Kalidindi, MHA; Jeah Jung, PhD; and Roger Feldman, PhD
The Development of Diabetes Complications in GP-Centered Healthcare
Kateryna Karimova, MSc; Lorenz Uhlmann, MSc; Marc Hammer, MPH; Corina Guethlin, PhD; Ferdinand M. Gerlach, MD, MPH; and Martin Beyer, MSc
Value-Based Health Insurance Design: How Much Does Socioeconomic Status Matter?
Bruce W. Sherman, MD, and Carol Addy, MD, MMSc
Insights on Site-of-Care Cancer Research: Both Quality and Cost Information Are Necessary to Guide Policy
Kavita Patel, MD, MPH, and A. Mark Fendrick, MD
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Ammarah Mahmud, MPH; Justin W. Timbie, PhD; Rosalie Malsberger, MS; Claude M. Setodji, PhD; Amii Kress, PhD; Liisa Hiatt, MS; Peter Mendel, PhD; and Katherine L. Kahn, MD
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Julius L. Chen, PhD; Andrew L. Hicks, MS; and Michael E. Chernew, PhD
Forgotten Patients: ACO Attribution Omits Those With Low Service Use and the Dying
Mariétou H. Ouayogodé, PhD; Ellen Meara, PhD; Chiang-Hua Chang, PhD; Stephanie R. Raymond, BA; Julie P.W. Bynum, MD, MPH; Valerie A. Lewis, PhD; and Carrie H. Colla, PhD
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Postdischarge Engagement Decreased Hospital Readmissions in Medicaid Populations
Wanzhen Gao, PhD; David Keleti, PhD; Thomas P. Donia, RPh; Jim Jones, MBA; Karen E. Michael, MSN, MBA, RN; and Andrea D. Gelzer, MD, MS, FACP
Trends in Primary Care Encounters Across Professional Roles in PCMH
Ann M. Annis, PhD, RN; Marcelline Harris, PhD, RN; Hyungjin Myra Kim, ScD; Ann-Marie Rosland, MD, MS; and Sarah L. Krein, PhD, RN
Inpatient Placement: Associations With Mortality, Cost, and Length of Stay
Daniel A. Handel, MD, MBA, MPH; Zemin Su, MS; Nancy Hendry, MSN; and Patrick Mauldin, PhD

Postdischarge Engagement Decreased Hospital Readmissions in Medicaid Populations

Wanzhen Gao, PhD; David Keleti, PhD; Thomas P. Donia, RPh; Jim Jones, MBA; Karen E. Michael, MSN, MBA, RN; and Andrea D. Gelzer, MD, MS, FACP
Postdischarge engagement of at-risk Medicaid beneficiaries in 6 health plans resulted in significant reductions in hospital readmissions at rates proportional to the frequency of engagement.
ABSTRACT

Objectives: To investigate the effect of managed care organization (MCO)-implemented postdischarge engagement, supported by other broadly focused interventions, on 30-day hospital readmissions in 6 at-risk Medicaid populations.

Study Design: Prospective cohort study.

Methods: One-year follow-up analysis of member claims data was performed following an intervention period from January 1, 2014, to December 31, 2014. Postdischarge engagement, supported by additional MCO-initiated interventions, was implemented to reduce 30-day hospital readmissions in Medicaid members having 1 or more dominant chronic conditions. Hospital readmission rates were calculated at baseline and at 1 year post intervention. Bivariable and multivariable generalized estimating equation analysis was used to quantify the likelihood of hospital readmissions.

Results: Following implementation, postdischarge engagement rates increased significantly, whereas provider follow-up rates remained unchanged. Increased member engagement resulted in statistically significant reductions in weighted readmission rates enterprise-wide (–10.1%; P <.01) and in 3 of 6 MCOs (–3.9% to –15.8%; P ≤.05) in 2014. Compared with nonparticipants, members who were successfully reached for postdischarge engagement displayed a 33% decrease in 30-day readmissions enterprise-wide (adjusted odds ratio, 0.67; 95% CI, 0.62-0.73) and a comparable decrease (–23% to –39%) in 5 of the 6 MCOs. In this context, greater frequency of postdischarge engagement was associated with proportionally decreased likelihood of readmissions.

Conclusions: Postdischarge engagement, against the backdrop of multifaceted MCO-implemented interventions, was associated with significantly reduced hospital readmissions in at-risk Medicaid subjects. Reduced likelihood of readmissions was observed at both the enterprise-wide and plan levels in a manner proportional to the frequency of engagement, a novel reported outcome for this population.

Am J Manag Care. 2018;24(7):e200-e206
Takeaway Points

Postdischarge engagement, supported by broadly focused stakeholder education and encounters, is effective in reducing hospital readmissions in a frequency-sensitive manner.
  • At-risk Medicaid beneficiaries who were successfully reached for postdischarge engagement displayed a 33% decrease in 30-day hospital readmissions.
  • Greater frequency of postdischarge engagement was associated with proportionally decreased likelihood of readmissions, both enterprise-wide and at the individual plan level, a novel reported finding for a Medicaid population.
  • Health plans can dramatically impact hospital readmission rates through greater postdischarge engagement and a variety of multifaceted interventions aimed at members, providers, and health plan staff.
Hospital readmissions signal gaps in the quality of care provided to patients. Of the 9 million Medicare patient hospitalizations per year,1 almost 1 in 5 are readmitted within a month of discharge and many more return to the emergency department.2 Many such readmissions are caused by inadequate discharge planning, poor care coordination between hospital and community clinicians, and the lack of effective longitudinal community-based care.

Best-practice recommendations to reduce readmissions have largely emerged from analyses conducted on commercial or Medicare fee-for-service populations, whereas relatively few analyses have been published on readmissions in the Medicaid managed care population.3 However, nonpregnant adult Medicaid patients experience readmission rates that are often higher than those experienced by Medicare beneficiaries. Readmission rates for adult (aged 45-64 years) Medicaid patients (22%)4 and those with heart failure (30%) are considerably higher than the corresponding rates in Medicare (16% and 25%, respectively).4,5 A retrospective analysis of Medicaid beneficiaries living in 19 states reported an average unadjusted 30-day readmission rate of 9.4% (range, 5.5%-11.9%).6 Hospital readmissions represent 12.5% of Medicaid payments for all hospitalizations, averaging $77 million per US state annually.6 Although value-based incentives, financing, and technical assistance can provide powerful drivers to minimize hospital readmissions, most attention in the literature to solving the readmission challenge has focused on Medicare and commercial populations.

However, with increased attention given to Medicaid expansion under the Affordable Care Act, effective approaches to minimize Medicaid hospital readmissions are increasingly being sought. In the pediatric Medicaid population, diseases of the respiratory system were the top cause of readmission, accounting for 21.2% of all readmissions,6 so a preponderance of Medicaid readmissions studies target pediatric asthma. A systematic review of 29 studies identified African American race, public or no insurance, previous admission, and complex chronic comorbidity as risk factors associated with pediatric asthma readmissions.7 The populations analyzed in 14 of the studies included (or were inferred to include) Medicaid beneficiaries.8-20 Three of the studies reported that the readmission rate of children with asthma insured by Medicaid was higher than that of comparable children with private insurance.11,16,19

Another systematic review retrieved 21 randomized clinical trials of transitional care interventions targeting chronically ill adults and further identified 9 interventions that demonstrated positive effects on hospital readmissions–related measures.21 Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Five of the studies had interventions that could be described as discharge management plus follow-up,22-26 2 as coaching,27,28 and 1 each as disease/case management29 and telehealth.30 All but 1 of the interventions29 led to reductions in readmissions through at least 30 days after discharge. The majority of these interventions were performed on elderly populations, and only 1 study consisted of a sizable Medicaid cohort.22

In 2014, AmeriHealth Caritas Family of Companies, a Medicaid managed care organization (MCO), implemented multifaceted enterprise-wide initiatives—including enhanced postdischarge engagement—to reduce 30-day all-cause readmission rates for plan members having 1 or more dominant chronic conditions, or a single condition of moderate chronic asthma, during the 2013 baseline period. We evaluate the impact of these initiatives in reducing hospital readmissions over a 1-year period enterprise-wide and across 6 MCO affiliates in 4 states (Pennsylvania, Louisiana, South Carolina, and Nebraska) and the District of Columbia (DC).


 
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