A CMS pilot aimed to reducing hospital readmissions seems to prove that age-old adage: all health care is local.

The project, which took place in 14 localities nationwide, was designed to see if improved care transitions could reduce rehospitalizations for Medicare beneficiaries. Quality improvement organizations took the lead in each of the communities and brought together providers and other caregivers in an effort to improve not just coordination between clinicians, but with social services as well. The results: the mean 30-day readmission rate per 1,000 beneficiaries fell from 15.21 in 2006-2008 to 14.34 in 2009-2010. That's a larger drop than in 50 comparison communities that did not implement the same interventions. In those communities, readmissions were 15.03 in 2006-2008 and 14.72 in 2009-2010. Hospitalization rates also fell by 5.74 percent in the 14 pilot communities.

Results of the pilot were released yesterday in JAMA. On a press call, Mary Ellen Dalton, R.N., president of the American Health Quality Association, a QIO membership organization, said that too often readmissions are viewed as a hospital problem. "But they are not just a hospital problem. They are not just a patient problem; they are a community problem," she added.

To that point, lead study author Jane Brock, M.D., said that the projects took a true population health approach. Brock, who is chief medical officer at the Colorado Foundation for Medical Care, said that the QIOs sought areas in their states where they could build effective community coalitions. Communities were defined by zip code and key providers were identified. The QIOs supported the coalitions and helped ensure that information was flowing between stakeholders.

Some of the interventions that proved most successful included using coaches to help patients with self-care, creating aides for home health, tool kits for nursing home residents, and using Project RED protocols, which seek to improve the discharge process. Another successful approach: communicate, communicate, communicate. In Washington, Brock pointed out, physicians who would be receiving discharged patients formed a working group to help educate hospitals on what kind of information they needed, how it should be transmitted and to whom. That went a long way toward improving patient handoffs, she said.

Brock and Dalton noted that HHS, through the Partnership for Patients and the ACA's Community-Based Care Transitions Program, hopes to mirror this type of community engagement on a broader scale. Both did add, however, that there are stumbling blocks, including the widespread adoption of information technology. While hospitals and physicians are required to implement IT systems under the meaningful use regulations, post-acute providers and other social agencies are not. Many of those organizations lack the sophisticated systems needed to tap into a health information exchange or a provider's EMR. That digital divide needs to be addressed, they said.