Ken Klaasmeyer, FACHE, and Peter Whited, M.D., explain how the Accountable Care Alliance will focus on improving patient outcomes, and the overall quality of health care provided.

The vast majority of patients who are hospitalized for a specific disease or condition receive good care while in the hospital. Yet a percentage of patients are back in the hospital within 30-60 days of their original discharge date. Key among the reasons for these readmissions:

• Patients do not understand discharge instructions — what is expected of them once they return home.
• Transitions or "hand-offs" from hospital-based providers to the patient’s primary care physician(s) are not well coordinated and sometimes incomplete.
• Patients fail to take accountability for their own health.

The Accountable Care Alliance brings together physicians who are committed to improving the health status of patients. Central to this goal is a discharge planning process that helps physicians and other providers monitor patient progress and, in particular, patient compliance with designated healthy behaviors. In other words, following the doctors orders on everything from what to eat to how and when to exercise. This is especially important for patients dealing with a chronic (ongoing) illness, such as diabetes, hypertension, heart failure, cystic fibrosis or sickle cell anemia. Daily follow-up calls and/or visits to patients following discharge from the hospital is one of many ways the physicians within the ACA can help patients reduce the expense and impact of repeated hospitalizations.

Providing high-quality care for any serious or chronic illness requires coordinated care from start to finish. Health professionals from the hospital to the doctor’s office to home must accept shared responsibility for both the quality and cost of care.

To facilitate that collaboration, the Accountable Care Alliance will establish "best practices" for the diagnosis, treatment and overall care of patients throughout the care continuum. Such "evidence-based" medicine brings together the best available research findings with recognized clinical expertise.

Some of the ways in which the ACA is focusing on quality include:

• Development and implementation of guidelines, called protocols, that indicate when and how to employ state-of-the-art medical devices and drugs.
• Performance reporting and benchmarking with peers on a regional and national basis.
• Standards for managing high-risk patients more proactively.
• Facilitation of information sharing with patients, including implementation of electronic health records and other Web-based health care information.