Reducing Hospital Readmission for those at Highest Risk in the Mystic Valley, MA

Dates: 2011

State: Massachusetts

Client(s): Hallmark Health System

Service: Health Care & Public Health Planning

Technical Expertise: Chronic Disease Management, Health Care Reform, Integrated Care Models


Hospitalizations are costly, accounting for approximately 31 percent of total health care expenditure. In Medicare, inpatient care accounts for 37 percent of spending, and readmissions contribute significantly to that cost. Eighteen percent of Medicare patients discharged from the hospital have a readmission within 30 days of discharge, accounting for $15 billion in spending. Multiple factors contribute to avoidable hospital readmissions: they may result from poor quality care or from poor transitions between different providers and care settings. Likewise, such readmissions may occur if patients are discharged from hospitals or other health care settings prematurely, are discharged to inappropriate settings, or do not receive adequate information or resources to ensure continued progression.

The reduction of inappropriate hospital re-admissions is one of the cornerstones of the Centers for Medicaid and Medicare Services (CMS) strategy to reduce the high and increasing cost of health care. In light of this focus, CMS created the Community Based Care Transitions Program (CCTP), which was developed as part of the Affordable Care Act to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

In 2011, JSI worked with Hallmark Health System, Cambridge Health Alliance, Somerville Cambridge Elder Services, and Mystic Valley Elder Services to develop and submit a successful application to CMS’ CCTP program. JSI worked with the project partners to compile, develop, and coordinate a root cause analysis in order to inform a multi-faceted community and hospital-based strategy to reduce hospital readmission for those at highest risk within the Mystic Valley basin community. In December 2011, the partner organizations were awarded funds from CMS.