One out of five Medicare beneficiaries hospitalized for heart failure is readmitted within 30 days of being discharged. Qualidigm, a Rocky Hill-based health care consulting organization, is trying to change that.
Two years ago, the company launched Communities of Care, a voluntarycollaboration among hospitals, nursing homes, rehabilitation centers, home health care providers and physicians. The initiative is designed to identify and implement strategies for improving communication and coordination among health care providers and improve education and health literacy for patients and their families.
“We recognized that heart patients are cared for across the continuum,” said Anne Elwell, Qualidigm’s vice president of community relations. “By working together to identify what information is needed to safely transfer a patient from one entity to another, for example, we can care for patients more effectively and reduce the chances they’ll relapse into another hospitalization.”
Communities of Care, which was developed in collaboration with the Connecticut Hospital Association, began with just two hospitals and quickly blossomed into a dozen. Now some 150 providers from across the state belong to 12 “communities,” each of which is centered on a hospital and includes various other affiliated entities. Physician partners, including primary care doctors, hospitalists and cardiologists, might belong to a number of communities based on the hospitals where they practice, just as rehab centers belong to the community for each hospital from which they receive patients. Members of each community meet monthly to identify issues such as gaps in communication when a patient is moving from a hospital to a nursing home, and implement solutions.
“This has been an absolutely incredible opportunity for all of us,” said Dr. Howard Dubin, a hospitalist at Midstate Medical Center. “Even though a patient is leaving our facility, we’re realizing that the patient is still the responsibility of the entire community and we need to work together as partners.”
Another component of the program is patient education. Working in conjunction with the University of Connecticut Health Center, Qualidigm recently produced “Heart Talk,” a video series that provides basic information aimed at keeping heart patients out of the hospital. One video is designed for patients and their families and caregivers, advising them on recognizing signs of trouble, medication management and other issues. Videos targeting nursing assistants and licensed health care professionals urge caregivers to speak in terms that patients can easily understand, for example.
Qualidigm is now working with Medicare officials to expand the program beyond heart patients.
“These strategies are transferrable to many other disease states,” Elwell said.
The Communities of Care initiative is helping “those of us who take care of patients expand our horizons,” Dubin said.
“We used to send patients out the door and say, ‘Good luck.’ Now we say, ‘Let us help you.’”
STATS
Name: Qualidigm
Address: 1111 Cromwell Avenue, Suite 201, Rocky Hill
Website: www.qualidigm.org
