Michael Bogaisky, MD December 19, 2012 - Research conducted by Michael Bogaisky, MD initiated innovative collaboration among CMO, the Division of Geriatrics, and several community-based SNFs to reduce avoidable hospital readmissions and improve the quality of care for geriatric patients. Results of Dr. Bogaisky's study demonstrated a strong association between Skilled Nursing Facilities (SNF) patients and high readmission rates at Montefiore.
To address the issue, Montefiore Care Management (CMO) and the Division of Geriatrics initiated collaboration between Montefiore’s senior medical and care management staff, Einstein-Montefiore Geriatrics Fellows, and SNF staff to identify and resolve the issues that lead to high hospital readmission among the SNF population. CMO has a long history of implementing programs and providing services to successfully coordinate care for patients, resulting in the “triple aim” of healthcare reform: improved health outcomes, better quality care and reduced costs. Montefiore and SNF staff have replicated existing care management practices, customizing and adapting them for the geriatric population. They took a team-oriented approach, fostering trust and increasing cooperation, to reduce patients’ transitions between acute and post-acute settings and improve their quality of life.
The collaboration combined many new and proven care management practices, including:
- case review to determine the root cause of readmissions
- sharing readmission data
- identifying risk factors for readmission and implementing new care delivery protocols to reduce transitions between SNF and Montefiore
- the establishment of complex case response teams
- instituting regular in-person meetings to improve communications, share knowledge, and identify gaps in care
The team has also focused on improving advanced care planning. The result has been a reduction in 30-day readmission rates from 33 percent to 15-20 percent at the collaborating SNFs.
The successful practices have been folded into programs for medical students, residents and fellows in training to prepare them for the future of healthcare.
Montefiore Medical Center recently received an Honorable Mention at the Association of American Medical Colleges (AAMC) Annual Meeting as part of the Readiness for Reform Health Care Innovation Challenge. Montefiore was one of 35 institutions to take part in the Challenge, which was designed to recognize programs within the AAMC membership that integrate innovations in research and education to transform healthcare delivery.
Dr. Bogaisky is a geriatrician at Montefiore and an Assistant Professor of Medicine (Geriatrics) at Einstein. In addition to quality of care improvement and hospital readmission reduction, his research focuses on the diagnosis and prognosis of chronic kidney disease in the elderly, prescribing patterns and decision-making processes for prescription of renally dosed drugs, and the ability of simple office based functional assessments to predict future disability and morbidity in the elderly.
The content of this annoucement was adapted from a recent issue of Montefiore Update.
2012 R4R Innovation Challenge Award (AAMC)
Montefiore Medical Center’s Regional Nursing Home Collaborative: Innovations in Post-Acute Care Transitions and Reductions in Readmissions