The Jewish Healthcare Foundation relies on PRHI research, which has identified patient-specific improvement opportunities that have informed the development of our quality improvement demonstration projects, attracted significant private foundation and public grant support, and positioned the organization as a trusted source of innovative and powerful program improvement models.
Using hospital discharge data (available through the Pennsylvania Health Care Cost Containment Council), our research (much of it reflected in a series of PRHI Readmission Briefs) moved us from problem-focused improvement opportunities (like reducing central line blood stream infections) to a more nuanced – and powerful – understanding of where healthcare waste lies. Ongoing analyses of the characteristics of patients hospitalized for exacerbations of common chronic diseases led us to better understand the complexity of the small group of patients that consume the majority of U.S. healthcare costs – an understanding that has shaped PRHI’s program agenda. For example:
- PRHI’s research team identified the high prevalence of behavioral health problems in patients with hospitalized common chronic diseases. This finding informed a pilot PRHI behavioral health integration project that eventually led to an Agency for Healthcare Research Quality (AHRQ)-funded, multi-state Partners in Integrated Care Project, and the Center for Medicare and Medicaid Innovation (CMMI)-funded, multi-state COMPASS project.
- We uncovered the role of complications or infections in driving almost a third of 30-day hospital readmissions of heart failure and chronic lung disease patients. This finding, together with our finding that almost half of admitted patients with chronic lung disease also have heart failure or coronary heart disease, informed our CMMI-funded Primary Care Resource Center (PCRC) Project. The PCRC Project focuses on bridging hospital-to-home transitions with better patient education, post-discharge home visits by trained care managers and pharmacists, phone calls, and primary care physician appointments for patients hospitalized with COPD, heart failure and/or acute myocardial infarctions.
- We dissected some of the reasons why 27% of HIV-positive patients admitted to the hospital are readmitted within 30 days – a rate that is 50% higher than the national average. On the majority of admissions, patients had diagnoses for common chronic diseases, along with behavioral health comorbidities – a finding that pointed to the need for multi-disciplinary care teams. In addition, the fact that two-thirds of 30-day readmissions occurred within two weeks of discharge highlighted the need for better care transitions. Both findings informed a funded quality improvement partnership with a major regional HIV/AIDS outpatient care clinic as well a current, Health Resources and Services Administration (HRSA)-funded initiative that aims to return HIV-positive individuals to receiving regular outpatient health care.