When health care services are not easily accessible in a community, people often call 9-1-1 or visit a local emergency room, resulting in increased health care costs, higher hospital readmission rates and poor health outcomes for patients.

Health Quality Innovators (HQI), the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Maryland and Virginia, is leading the nation in the number of readmissions avoided and has achieved a cost savings of $61 million through its efforts to help communities in Maryland better coordinate care for seniors.

HQI’s success is driven by data, education and partnerships. Attendance at in-person meetings to discuss quarterly data reports has been instrumental in helping HQI stay on top of the needs of each community and helping them understand how and what to look for in their data. For example, HQI helped a hospital and skilled nursing facility (SNF) analyze a readmissions report to determine the cause of readmissions to the hospital from the SNF. The report showed the hospital had a number of sepsis readmissions, and the SNF had a high rate of urinary tract infections, an early symptom of sepsis. The hospital, in partnership with the SNF and with the help of HQI’s nursing home team, provided more education to SNF staff about sepsis and the early warning signs.

While the data show where more resources and education are needed, HQI’s role as a convener, linking seemingly unlikely partners, has made the biggest contribution to the reduction of readmission rates and improved care coordination within communities.

In Wicomico County, a rural area of the state, resources are extremely limited. HQI’s data analyst developed a report illustrating the percentage of Medicare beneficiaries in each ZIP code with a specific diagnoses such as diabetes, heart disease or hypertension. The report helped the county realize that some of its educational resources—for diabetes as an example—were being spent in areas without the highest rates of diabetes.

While the data show where more resources and education are needed, HQI’s role as a convener, linking seemingly unlikely partners, has made the biggest contribution to the reduction of readmission rates and improved care coordination within communities. “Sometimes connecting people and organizations to the resources they need means thinking outside the box," said Kelly Arthur, one of HQI’s Improvement Consultants in Maryland.

Arthur’s background in social work allows her to think differently about who should be at the table to help address issues in a community. For example, in Prince George’s and Montgomery Counties, the police department, Emergency Medical Technicians and other health care leaders meet monthly to discuss “challenging” patients—those who are consistently readmitted to the hospital. At a recent meeting, Arthur suggested finding out if some of these patients were veterans, which would make them eligible for services the counties may not otherwise have been able to offer.

Looking ahead, HQI will continue to foster partnerships within each community with a focus on sustainability. This includes helping communities identify and secure funding opportunities, spreading promising partnerships with other communities, helping providers and other health care leaders understand information in the state Health Information Exchange, and continuing to help communities understand their data.