Broad-based, integrated, community-wide initiatives can help keep seniors out of the hospital, says an important new study from the Journal of the American Medical Association.

The study, done by a team led by Dr. Joanne Lynn of the Altarum Institute’s Center on Elder Care and Advanced Illness is new evidence that by working together, hospitals, physicians, social workers, nursing homes, home health agencies, and community organizations can help seniors reduce both initial hospitalizations and readmissions. This suggests that such teamwork can improve the quality of care for elders with chronic disease.

The researchers looked at 14 initiatives across the country, all involving Medicare Quality Improvement Organizations (QIOs). These are private, Medicare-funded groups that work with medical providers and seniors in each state to improve the quality and efficiency of health care. The study looked at networks in a broad range of communities throughout the country from Miami, FL to Whatcom County, WA. The sites were rich and poor, urban and rural, and those with relatively high hospital usage and those with lower utilization.

Participants used a wage range of methods to reduce hospitalizations. Nearly all used care transition nurses who are specially trained to coach high-risk patients in ways to care for themselves. Most used Project RED (Re-Engineered  Discharge) that standardizes hospital discharges. Nursing homes used software called INTERACT which helps nurses identify and manage residents’ changing health status. What’s striking is these are all readily available off-the-shelf tools that any facility can use.

Some of the programs also used community relationships to help seniors stay out of the hospital. The program in Tuscaloosa, AL, for instance, built on ties with local churches. I have written in the past about a similar model in Memphis TN that aims to accomplish the same goal.  

In other communities, hospitals and nursing homes did a better job sharing data. In others, nursing facilities changed the way they cared for new admissions. My friend Joanne Kenen wrote a nice piece for Politico describing how some of these local projects operate.

The bottom line is that both initial hospitalizations and rehospitalizations were lower in the 14 communities than in 50 similar communities that did not use these interventions.

There are several important caveats to this study. The first is that fewer hospitalizations are not necessarily the same as better care.  It was also hard to find perfect matches between those communities that used the initiatives and those that did not. It also turned out that hospitalizations and readmissions declined in both sets of communities, though they fell more in those that implemented quality programs. Finally, while admissions and readmissions fell, rehospitalizations as a percentage of discharges (a commonly used measure) did not.

Still, this study builds on a growing body of evidence that when doctors, hospitals, nursing homes, community organizations, and patients themselves work together, seniors are more likely to do a better job caring for themselves. And that can keep them out of the hospital, which is usually  a very good thing.