Between value-based purchasing and other payment provisions in the Affordable Care Act, readmissions have been thrust into the spotlight. Lawmakers and regulators are using the power of the purse to try to curb the rate of rehospitalizations, putting in place significant payment penalties for providers. In a couple of years, hospitals with excessive readmissions rates will begin to see cuts in Medicare reimbursements.

Hospital leaders are quick to point out that reducing avoidable readmissions is a team effort that includes everyone in the care continuum. Since 2009, 148 hospitals in Massachusetts, Michigan, Ohio and Washington have been working with more than 500 cross-continuum partners to reduce rehospitalization rates and improve transitional care. The project, known as STAAR — STate Action on Avoidable Rehospitalizations — is spearheaded by the Institute for Healthcare Improvement and some early results are beginning to trickle out.

"A few years ago the field of readmissions was focused around doctors treating disease properly; now with STAAR, we focus on hospitals working with providers in the community," says Amy E. Boutwell, M.D., president of Collaborative Healthcare Strategies in Lexington, Mass., and the co-principal investigator of STAAR.

According to Boutwell, there are 50 hospitals in Massachusetts implementing the cross-continuum model, and "Massachusetts is the only state in the country where a supermajority of all hospitals in the state are working to reduce readmissions in this way."

One Massachusetts hospital having success is Baystate Medical Center in Springfield. The medical center recently began a review across the care continuum for five readmitted patients. The goal was to find ways to improve transitions of care. "They've improved patient and family education techniques, examined 30-day readmission rates, provided timely communication to community-based providers, and ensured that follow-up plans are made prior to discharge," Boutwell notes.

"Baystate is seeing fewer readmissions because of STAAR," says Paula Griswold, executive director of the Massachusetts Coalition for the Prevention of Medical Errors, and one of the co-authors of the STAAR initiative. "It's the net effect of everything they're doing."

Readmission rates also have decreased significantly for some Washington hospitals, according to Carol Wagner, vice president of patient safety for the Washington State Hospital Association in Seattle. "Rehospitalizations have been reduced, especially in the area of congestive heart failure, through a patient-centric coordination of care," Wagner says. "This means follow-up calls after discharge and visits with a nurse coordinator at home or in a clinic setting."

Despite its successes, the STAAR initiative has presented challenges.

"People have to come together across organizations and they're being asked to act like an integrated delivery system," says Griswold. "It's very different than what they were doing before."

Boutwell adds, "Educating providers on how to improve readmissions takes time and it costs money to reduce readmissions. But hospitals see this as a strategic investment for the future."