Developing Care Continuum Partnerships for ACOs an “Enormous Challenge”

As hospital readmissions continue to be costly and suggestive of poor quality of care, researchers have found that the path to improved coordination could rely on a multi-state approach to care transition programs. 

However, developing collaborative relationships between hospitals and other outpatient facilities have proven to be a “an enormous challenge.”

The STate Action on Avoidable Rehospitalizations (STAAR) program aimed to produce statewide reductions of 20%-30% in readmissions through a combination of individual provider, community and statewide approaches in Massachusetts, Michigan and Washington. 


What STAAR found was that hospitals agreed that recruitment of providers across the care spectrum was “a real struggle,” mainly because these entities’ opportunity costs of investing in reducing readmissions was too high.

Reasons for this were based in part because of the competitive nature of health care delivery and limited-to-no previous experience working together on quality improvement. 

Particularly, STAAR hospitals had problems recruiting and engaging primary care physicians, frontline nursing home staff and caregivers from outside of their own organizational networks or health systems. 


While some hospitals embraced this challenge, STAAR found that others never stopped trying to recruit representatives from this pool of providers.

Regardless, getting people “at the table” did not assure progress.

Often, the study noted that participants did not have preexisting relationships with other organizations nor did they have an understanding of each other’s roles in the care process. 

As a result, participants said they had to build relationships that were not previously there, while others said there were significant gaps in understanding the different organizations’ and providers’ roles and capabilities. 

“Initially, it was a period of discovery where everyone is sort of trying to understand what everyone else does and see if there’s opportunity to reference different skill sets to get better outcomes,” researchers wrote. 

While reduction of hospital readmissions can be seen as an opportunity to address costly and often uncoordinated care, it will take an extensive effort to provide new and better communication between community providers, the study writes. 

Written by Jason Oliva