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HealthInsight New Mexico Supports Four New Mexico Communities in Improving Care Transitions

JAMA Article Confirms Value of Local Approach to Reducing Hospital Readmissions

The JAMA article describes community-based projects in 14 states that produced an average 6 percent decrease in hospitalizations and re-hospitalizations over two years, nearly twice the pace of comparison sites. Conducted between 2008 and 2011, the project was performed by Medicare Quality Improvement Organizations (QIOs) with funding from the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare. This project formed the foundation for work currently being done locally by HealthInsight New Mexico.  

As New Mexico’s QIO, HealthInsight New Mexico has provided support for coalitions focused on reducing avoidable hospital readmissions in Rio Arriba and Sandoval counties, Taos and Santa Fe. Following the model described in the JAMA study, these coalitions bring together hospitals, nursing homes, home health care agencies, and social service agencies such as Area Agencies on Aging.

One such coalition, the Rio Arriba Community Health Council, includes the local hospital, federally qualified health centers, behavioral health organizations, Northern New Mexico College, substance abuse programs and the Area Agency on Aging.

When deciding on its focus of activity, the council learned through data analysis that, though the county hospital’s readmission rates were low, scores on patient satisfaction of the care experience were not optimal. The coalition sought to identify reasons. They identified the most frequent users of the hospital emergency department over a year and built a system to connect these frequent users with community health worker “navigators” who helped them connect them with a primary care provider and community services to lessen their dependence on the emergency room for non-emergency needs. They were able to reduce ER usage among their clients by 21 percent. As a result of this project, the hospital refers its most frequent users with complex health needs to care coordination. It is estimated that care navigators can save as much as $2.6 million by assisting 10 high-need patients, while also improving their quality of life.

Rio Arriba Health and Human Services (HHS), which leads the coalition, also manages the county’s adult daycare services and collaborates closely with senior services. Immunization rates for seniors in Rio Arriba have increased by 28 percent by assisting community partners in providing free immunizations at senior centers, in retail outlets and the hospital, as well as immunizing homebound seniors in their homes. Their next task is to build a process for identifying at-risk seniors to connect them with the appropriate services so they don’t depend on the emergency room to meet all of their health needs.

“We’ve discovered we can bring our community together to provide preventive care,” said Lauren Reichelt, Rio Arriba HHS director. “It’s really fun. We have music, farmer’s markets, car shows - you name it - in conjunction with health services. Everyone turns out, even our Congressman!” Rio Arriba Commission Chairman Barney Trujillo added, “This isn’t just good for our health. It strengthens our community.”

HealthInsight New Mexico coaches and provides technical support to communities like Rio Arriba County to improve care for all citizens and particularly seniors. They do this by understanding causes, applying medical research findings in a way that meets the specific needs of the community, and helping measure the impact of projects like the immunization program.

“We approached HealthInsight New Mexico early on, and we’ve benefitted highly from our relationship with them,” Reichelt added.

“Our health care system is complex,” said Sheila Conneen, PhD, MPH, MSN, ANP-BC, HealthInsight New Mexico’s lead on care transitions activities. “Elderly people with chronic conditions rely on many providers and services, not all of them medical, so a commitment to shared, local responsibility from all who are involved in the care process is important. We congratulate our New Mexico communities on their commitment to breaking down organizational boundaries to do what is best for the patient, and look forward to celebrating their successes.” 

The efforts that HealthInsight New Mexico is undertaking are part of a national project that is transforming health care in more than 400 communities across the country. More details about this national effort: