External Peer Review Program
A site for data collection specifications, facility reports and reconsiderations
Community Coalition
Hospital Readmission Reduction
PROJECT
Partnership for Community Health Initiative
WHAT WE DID
Formed community coalitions for readmission prevention
Setting
Medicare beneficiaries across PA and WV
TIMELINE
2020 - 2022
The Project
- Quality Insights transformed healthcare delivery across Pennsylvania and West Virginia through the creation of 13 strategic community coalitions designed to address avoidable hospital readmissions. This innovative approach brought together healthcare providers, community organizations, and community members to tackle one of the most persistent challenges in Medicare care coordination. The coalitions provided complete geographic coverage across both states, ensuring that every Medicare beneficiary had access to improved care coordination services.
- Each coalition operated as a collaborative network that addressed the complex factors contributing to hospital readmissions, including inadequate discharge planning, medication management issues, lack of follow-up care, and social determinants of health that affect patient outcomes. Our teams worked closely with coalition members to identify local barriers to effective care transitions and develop targeted interventions that addressed the specific needs of their communities.
The Challenges
- Fragmented healthcare systems with poor communication between providers
- Lack of standardized discharge planning processes across different hospitals
- Social determinants of health barriers affecting patient ability to follow care plans
- Limited availability of post-acute care services in rural communities
- Medication management issues including cost barriers and complex regimens
- Resistance from some providers to participate in collaborative improvement efforts
- Difficulty tracking patients across multiple healthcare systems and settings
The Results
- Between 2020 and 2022, this collaborative work resulted in 17,000 fewer avoidable hospitalizations across West Virginia and Pennsylvania, generating a remarkable cost savings of $244 million to the Medicare program and healthcare system.
- In Pennsylvania alone, the coalitions achieved 14,319 fewer readmissions, translating to $208 million in cost savings, while West Virginia's coalitions contributed 2,774 fewer readmissions with cost savings of $35.3 million.
- Beyond the impressive financial impact, these results represented thousands of Medicare beneficiaries who received better coordinated care, avoided unnecessary hospitalizations, and experienced improved health outcomes.
- The coalitions also expanded their focus to address chronic disease prevention and management, particularly diabetes and heart disease, creating a comprehensive approach to improving population health in their communities that established lasting partnerships and sustainable care coordination processes.