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Trenton Health Team Works to Reduce Costly Hospital Readmissions

Trenton Collaborative Expands Scope of Novel Approach With Medicare-Designated Healthcare Quality Institute for NJ

TRENTON-The Trenton Health Team’s care coordination efforts helped reduce 30-day hospital readmissions in Mercer County by 6.8% between 2011 and mid-2012. The THT, a coalition of hospitals, community health centers and Trenton’s health department, has made care coordination one of its five strategic initiatives. By sharing data as never before among the hospitals and several area nursing homes, the THT and the broader Greater Trenton Community Coalition have started to see significant benefits both in quality of care and in cost reductions.

This effort is in line with work being led more broadly by the Healthcare Quality Strategies, Inc. (HQSI), the Medicare-designated Quality Improvement Organization for NJ. An article just published in the Journal of the American Medical Association (JAMA) detailed similar work done by HQSI on a smaller scale in 2009-10, and reported 6% average declines in re-hospitalizations and hospitalizations. Currently, the greater Trenton area is one of several HSQI communities in NJ where the same approach is being used on a larger scale over a broader geographic area with more healthcare partners, including THT.

“THT is collaborating with area skilled nursing facilities and physicians to provide more care in those facilities and to develop novel approaches to ensure that Medicare recipients have close follow up after hospital discharge to prevent complications that result in hospital readmission,” said Dr. Robert Remstein, the President of the Trenton Health Team and Vice President for Accountable Care at Capital Health.

Hospital readmission within the first month of discharge is a common, costly occurrence for Medicare patients. A quarter of Medicare’s heart failure patients are readmitted to the hospital within 30 days of discharge. Nationally, avoidable 30-day hospital readmissions for all diagnoses cost the Medicare program billions of dollars each year.

The care transitions work described in the JAMA study dovetails with THT’s focus on Community Wide Clinical Care Coordination, which includes coordinating patient care across different care settings. By providing greater access to primary care and coordinating health services, THT is helping ensure that patients receive the high-quality care they need in a primary care medical home.

THT partners Capital Health, St. Francis Medical Center and Henry J. Austin Health Center were all part of the initial meeting with HSQI that resulted in the formation of the Greater Trenton Community Coalition, which includes other Trenton area healthcare providers. Coalition members agreed that a community-wide, collaborative data-sharing approach across healthcare settings could mean better outcomes and lower readmission rates for the county’s Medicare patients. Mercer County was ranked 16 out of 21 New Jersey counties in 30-day readmission rates for Medicare patients in 2009. Since the partners of the Coalition began sharing data and working together in 2011, the county’s readmission ranking is trending in the right direction, improving to 13 out of 21 counties as of June 2012 (HQSI Care Readmission Data).

THT is committed to working with the Coalition to continue to reduce avoidable readmissions from the 2012 rate of 20.2% to 17.1% (an additional 15% reduction) by the end of 2013. THT is working to reduce inappropriate hospital readmissions for individuals with chronic conditions such as congestive heart failure, acute myocardial infarction, chronic obstructive lung disease, diabetes, and pneumonia.

THT is also focused on end of life care transitions and has commenced a new initiative to determine how to improve access to palliative and hospice care for individuals with end-stage chronic medical conditions for which no further treatment can be offered beyond keeping patients comfortable. THT will work closely with the faith community on this effort.

In addition to THT and HQSI, the Greater Trenton Community Coalition includes greater Trenton area healthcare providers Arcadia Nursing & Rehabilitation Center, Bayada Home Health Care, Care Alternatives, Inc., CareOne at Ewing, CareOne at Hamilton, Compassionate Care Hospice, Embracing HospiceCare of New Jersey, Fresenius Medical Care, Greater Trenton Behavioral Health Care, Greenwood House Home for Jewish Aged and Greenwood House Hospice Services, Inc., Hamilton Continuing Care Center, Hamilton Grove Healthcare & Rehabilitation, Jewish Family & Children’s Services, Mercer County Office on Aging, Mercerville Center – Genesis Healthcare, Mercer Street Friends Center, Merwick Care & Rehabilitation Center, The Millhouse, Pavilions at Forrestal, Penn Cardiac Care at Mercer Bucks, Princeton HomeCare Services, Renal Ventures Dialysis Center of Trenton, Robert Wood Johnson University Hospital at Hamilton, Robert Wood Johnson Visiting Nurses , Saint Lawrence Rehabilitation Center, Vitas Innovative Hospice , VNA Home Care Of Mercer County, and Water’s Edge Health Care & Rehabilitation Center.

About the Trenton Health Team
Trenton Health Team (THT) is an alliance of the city’s major providers of healthcare services including Capital Health, St. Francis Medical Center, Henry J. Austin Health Center and the city’s Health Department. In collaboration with residents and the city’s active social services network, THT is developing an integrated healthcare delivery system to transform the city’s fragmented primary care system and restore health to the city. THT aims to make Trenton the healthiest city in the state. The THT receives generous support from The Nicholson Foundation, corporate partners and other foundations. For more information, visit