Why hospitals should align with aging agencies to reduce readmissions

Area Agencies on Aging, or AAAs, coordinate social services for older adults in communities across the country. And when they form informal partnerships with various healthcare organizations, they've been linked to significantly lower readmission rates, according to new research published in Health Affairs.

Hospitals that don't meet certain benchmarks in regards to 30-day readmission rates face financial penalties from the federal government, and many are using multi-pronged approaches to drive improvement in that area, including community-based population health initiatives.

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Readmissions aren't the only metric that can be improved by partnering with AAAs; the research also found that communities whose AAAs had programs to divert older adults from nursing home placement had lower avoidable nursing home use, compared to areas in which AAAs lacked such programs.

The findings underscore the importance of health outcomes in bolstering a health organization's bottom line. AAAs can provide a means of affecting health outcomes on a community level; between 40-90 percent of poor health, according to the research, is attributable to social, behavioral and economic factors that typically fall outside the purview the healthcare system.

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For older adults in particular, there's evidence that social services -- housing support, nutrition assistance and income support among them -- can improve health and reduce the need for costly medical care.

That's where AAAs come in. They've historically facilitated services that enhance the independence of seniors, such as in-home care, case management, home-delivered meals and transportation. In some areas, AAAs partner with hospitals and insurers to link social services with those seniors identified by providers as especially vulnerable, including those with recent hospitalizations or nursing home stays, as well as enrollees in Medicaid managed care programs.

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Established under the Older Americans Comprehensive Services Amendments of 1973, there are 622 AAAs across the country in a network called the National Association of Area Agencies on Aging, and that national reach means that effective strategies can be scaled up.

Interestingly, the findings show that partnerships with AAAs are more effective when they're informal. They lead to more effective holistic support for older adults, preventing bad health from getting worse and thereby reducing readmissions.

Formal partnerships, by contrast, weren't linked to reduced readmissions. In fact, they were linked to higher Medicare spending per beneficiary.

The authors contend this isn't as counterintuitive as it may seem. Informal partnerships often grow organically from collaborative work, they're fostered by regional institutions, such as coalitions, that allow AAAs to coordinate with other organizations and allow them, in turn, to coordinate among themselves. 

Informal partnerships maintained by an AAA might point to a dense web of interconnectedness across community organizations, which could support the handoffs needed to help patients recover after hospital discharge -- thus avoiding readmission.

Formal relationships, on the other hand, are often contractual and imply bilateral agreements, meaning they may be less representative of the habits of coordination among community organizations. That in turn may explain the lack of association with readmission rates.

Some payers and providers are expanding efforts to connect patients with social services, the authors said. One example is the newly launched accountable health communities model of the Centers for Medicare and Medicaid Services.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com