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20 ways to reduce readmissions


One in five elderly patients are readmitted to the hospital within 30 days of leaving, according to government data.


One in five elderly patients are readmitted to the hospital within 30 days of leaving, according to government data. This revolving door of Medicare patients alone costs $26 billion annually, with $17 billion paying for trips that could be prevented upon patients receiving the right care. Experts point to poor discharge planning and care coordination of patients as the main causes for readmissions, specifically for patients with congestive heart failure, acute myocardial infarction (heart attacks) and pneumonia. Many are being discharged without fully understanding their treatment plans and, as a result, do not stay adherent to prescribed medications. The good news? Up to 75% of  readmissions are preventable, according to research. 

As stakeholders continue to develop more forceful penalties-and also incentives-aiming to lower costs and improve quality under the Affordable Care Act, the pressure to reduce readmission rates will only intensify. While hospitals have developed several strategies to avoid readmissions, they are often labor intensive with questionable return on investment. One workaround is to send patients to observation stays rather than inpatient care, however, this can create additional costs for patients. After consulting industry experts from across the continuum, MHE has compiled 20 of their top suggestions, including the importance of utilizing data and analytics to track chronic illness, increasing patient education and participation in treatment, and more effective collaboration between  payers and providers. While opinions varied, the overall goal of reducing readmissions remained imperative. Tell us your solutions on Twitter @MHExecutive.



Let’s talk: real-time

Imagine the promise of technology that uses real-time healthcare data to predict undiagnosed diabetes. What if primary care physicians could reach out and treat these at-risk patients before they develop the disease? Before they have a crisis that sends them to the hospital? Before they are at risk for a readmission? When your primary care physician doesn’t have all the facts about your recent hospital stay, it’s hard to get effective follow-up care after you leave the hospital, and that could lead to your being readmitted.  Independence helped create a new collaborative health information exchange (HIE) in southeastern Pennsylvania that will facilitate the real-time exchange of data among doctors, hospitals and health insurers, which will help reduce readmissions.

- Daniel J. Hilferty, president and CEO, Independence Blue Cross



Build the technology infrastructure

There are two root cause drivers of readmissions that healthcare organizations will need to look beyond their electronic health records (EHRs) to address: real-time physician-to-physician communication and upstream social determinants of health. Understanding and cost-effectively addressing these two underlying drivers are prerequisites for any cost-effective and sustainable strategy to reduce preventable readmissions, above and beyond routine discharge planning, follow-up, care coordination and patient self-management skill development. Leveraging technology to address both drivers holds the potential of reducing some labor costs associated with  care coordination.

Bridging transition care communication gaps will require every healthcare organization to modernize their aging communication and collaboration infrastructure across the care continuum. Touchtone phones, overhead pages, Rolodex directories, phone tag, voice mail, fax, paper memos, multiple phone numbers for the same person and sharing EHR documents between facilities are no substitute for real-time presence and communications on the same mobile device that clinicians use for their full-function EHRs.

- Dennis Schmuland, MD, FAAFP, chief health strategy officer,  US Health & Life Sciences, Microsoft Corporation



Big data can mean big improvement  in patient outcomes

Along with other industries, healthcare is working to take advantage of disruptive trends, such as cloud, social, mobile and big data. Together, these trends (“the third platform”) are redefining the applications and technology we use, creating significant new opportunities in health IT, including opportunities around remote patient monitoring and communication-key components in reducing readmissions. Leveraging the patient data created by disruptive trends, providers are able to identify those at greatest risk and make informed care decisions.

According to recent research, one in three federal agencies focused on healthcare research and care delivery say they have successfully launched at least one big data initiative. Additionally, research shows that 35% use big data to improve patient care, 31% are reducing care costs, 28% are improving health outcomes and 22% are increasing early detection. Advanced analytics makes this possible. Advanced analytics provides predictive capabilities to answer “why?” and “what will happen next?”

Unique analytics platforms like this may be the missing link in healthcare data-it has insights picked up in the patient’s home environment. Taking steps now to build these capabilities will be critical as providers manage risk, contain costs and positively impact patient care outcomes into the future.

- David Dimond, chief technology officer, Global Healthcare, EMC



Utilize newer technologies

Many of today’s transitions of care programs are labor- and resource-intensive. Newer technologies offer a means to improve efficiency, optimize the efforts of clinicians and reduce readmissions.  Physicians are already taking on additional tasks as a result of new quality initiatives. The volume of information they touch and manage can be overwhelming-including discharge summaries and patient records.

Event-based notifications can help streamline activities in several ways. They can inform physicians when a patient is admitted to or discharged from a hospital. Notices can also be configured to help physicians stay on top of high-risk patient groups. These notifications can arrive via text messages, email or through an EHR system based on the physician’s preferences. This helps the physician’s office ensure timely outreach to the patient to schedule appropriate follow-up care-often within a matter of hours. Event-based notices that use newer technology are often faster than many of today’s care transition programs.

Because many studies have shown that timely follow-up (ideally within five days) is key to reducing readmissions, it only makes sense that the industry implements a better solution to eliminate this outdated, inefficient process.

- David Palkoner, vice president, product management, Medicity



Share care plans at every transition

As healthcare leaders, we must not overlook the role that technology can play in addressing readmission rates. For discharged patients, providers can help accelerate care coordination by digitally sharing care plans at every transition step, and not just in one direction, but truly ‘bi-directional’ care coordination.

In Massachusetts, we’re seeing providers who are successfully utilizing this system, including national leaders such as Dr. Larry Garber and Dr. Terrence O’Malley, co-investigators on the Improving Massachusetts Post-Acute Care Transfers (IMPACT) project.  In addition, we’ve seen regional hospitals and their partners utilizing technology to address this challenge. Milford Regional Medical Center (MRMC) and their care partners are using the Massachusetts HIE, the Mass HIway, to address readmissions. In one case, MRMC identified a patient who was readmitted 11 times, compiling a total of 58 days in the hospital, which included 54 separate studies and 24 chest X-rays.

MRMC chose to tackle this specific type of care challenge by providing documentation electronically to those facilities and organizations that assume care for the patient after discharge. Additionally, the hospital is working collaboratively with their referral partners to receive patient information upon admission and have the information flow directly into its EHR system.

Connected communities or groups of referral partners that digitize their healthcare data and share it via an HIE can have a significant impact on lowering costs and improving outcomes. According to an article in the journal Applied Clinical Informatics, the use of health information exchange in the emergency room lowers readmissions by 30%. Sharing care plans through a health information exchange improves patient monitoring, post-discharge appointment adherence and medication reconciliation and adherence. 

- Laurance Stuntz, director, Massachusetts eHealth Institute



Harness data in new ways

We’re unlocking the power of data-and not only structured data, but the unstructured data that’s so vital to identifying readmission risk. Evidence indicates that a major readmission factor is the presence of specific clinical and social indicators not necessarily related to the reason for admission-underlying chronic disease, for example. Often, however, those details are captured within narrative portions of the patient record, not as structured data. A holistic view is needed; experience is starting to suggest that predictive modeling is much stronger when unstructured data is included as input. By aggregating and analyzing unstructured data and synthesizing it with structured data, healthcare organizations can improve prediction and allow individual high-risk ‘needles’ to be found-and proactively cared for-within the patient population ‘haystack.’

- Chris Tackaberry, MD, co-founder & CEO, Clinithink



Close gaps in care with medication management, adherence programs

Health plans and pharmacy benefit managers (PBMs) can close gaps in care through collaborative clinical programming, which capitalizes on strengths and core capacities on each side. Medication therapy management (MTM) programs aide in post-discharge medication reconciliation, comprehensive review of new and existing therapies and patient consultation. Medication adherence programming ensures that patients fill discharge medications as directed and remain tightly adherent to those medications to minimize the likelihood of recurrent events. Retrospective drug utilization review (RDUR) programs provide a tool to routinely monitor the post-discharge patient and identify potentially unsafe and clinically inappropriate utilization of medications. And lastly, clinical analytics can be utilized to better stratify high-risk patient populations for more aggressive post-discharge monitoring and intervention.

- David Calabrese, RPh,  vice president and chief pharmacy officer, Catamaran



Outreach is powerful

Medication reconciliation-patients understanding which medications they should be taking upon discharge, and which they should not-is critical in preventing readmissions.  Outreach calls from case management, home care visits and/or early outpatient follow up help reduce risks of medication errors. Ensuring seamless and rapid transfer of patient information from an inpatient to outpatient setting, such as discharge summaries, is critical and can also be facilitated.

- Scott Josephs, MD, vice president  and national medical officer, Cigna



Build lasting payer/provider relationships

Readmissions can often be avoided and may offer payers and health systems significant collaboration opportunities to ensure that patients receive proper and timely care, thereby leading to the avoidance of what are, in many cases, unnecessary events. Additionally, readmissions occur because of simple and avoidable reasons. For example, patients are readmitted because they don’t follow their discharge instructions or fill their medications or perhaps because they don’t have follow-up appointments with their doctors. Solutions can be found in basic concepts and ideas: make certain the patient has a follow-up visit scheduled and confirm that the patient is working with a care coordinator or payer-sponsored “health coach.” Payers and providers need to partner up to ensure that their patient discharge programs and outreaches work in tandem and not disparately. Simply stated, we don’t need to reinvent the wheel when we think about activities around readmission prevention. Many of the best ideas lie in payer/provider collaboration and also through some very basic and common-sense solutions.

- Douglas L. Chaet, FACHE, senior vice president, contracting and provider networks, Independence Blue Cross



Clinical collaboration, appropriate incentives will help

A collaborative relationship with the managed care organization and the treating physicians in the form of providing timely information, clinical collaboration and appropriate outcome-based incentives (such as enhanced payments for reduced unnecessary readmissions) should become the standard for mitigating the scourge of avoidable readmissions in the future.

- Scott Josephs, MD, vice president  and national medical officer, Cigna



Align incentives  around fee-for-value

The fee-for-service model rewards volume and not necessarily efficiency. It also can create the sort of relationship between payers and providers that can sometimes trap patients in the middle. Transitioning to a fee-for-value incentive model will deliver better long-term solutions by incenting quality of outcomes, rewarding efficiency and aligning the business incentives of the healthcare system with the consumers’ needs. Care decision-making responsibility is shifted to where it is most effective, at the level of the doctor and patient. By design, the fee-for-value model unites payers and providers with a shared goal to work together to get the right care to the right patients in the right setting. The outcome is improved quality care for patients, greater efficiency and lower costs. 

To accomplish this, we must work collaboratively with the understanding that there is more than one solution to solving these challenges.

Accountable care organizations are a wonderful innovation, but they don’t necessarily work equally well for all types of care or in all locations. Therefore, our industry must continue to experiment with a variety of value-based care delivery models, from medical homes, to bundled care and beyond. By partnering with providers in new ways, health plans become less of a regulator of care and more of a facilitating partner in high-value care delivery. 

- Stephen L. Ondra, MD, senior vice president and chief medical officer, Health Care Service Corporation (HCSC)



Create unified incentives for stakeholders

One of the major challenges to hospital readmission improvement is the non-alignment of incentives. Specifically, at the point of the potential admission decision, hospital providers are often focused on inpatient admission (as opposed to outpatient observation status).

The factors driving the admission decision are commonly rooted in outdated beliefs in the advantage of inpatient (over outpatient) care and hospital directives predisposed toward inpatient admission. At discharge, the attending provider (e.g., hospitalist) can be influenced toward early discharge by such historical performance measures as excessive inpatient bed day counts. Both of these forces increase the potential for unnecessary readmissions.

More than at any previous time, the managed care industry needs to align the hospital provider, the hospital executive and the outpatient care management service providers to create unified incentives toward appropriate inpatient admission/discharge decision-making and thereby minimize unnecessary readmissions. New and more creative solutions to “total patient management” engaging all parties involved in the care provision continuum will be necessary.

- Ronald H. Bolding, president and CEO, Inter Valley Health Plan



Take steps to mitigate risks  with provider transitions

Preventing avoidable readmissions is first and foremost a quality issue.  An unnecessary readmission that is prevented is a win/win/win scenario for the patient, the healthcare professional and the benefit plan sponsor as outcomes are improved and costs are reduced.

The transition from one setting to another, such as from a hospital to sub-acute facility or home, is fraught with risks inherent in handoffs, especially for patients with complicated cases. Understanding these risks and taking steps to mitigate them through a coordinated and collaborative effort by healthcare professionals and managed care organizations alike is the key priority.

- Scott Josephs, MD, vice president and national medical officer, Cigna



Consider post-acute care hospitalists

Hospitals that closely partner with their post-acute care providers in their community-post-acute care hospitalists, in particular-can help ensure that patients continue to receive the appropriate care they need with fewer incidences of readmissions. The Centers for Medicare & Medicaid Services (CMS) allows patients that present to an emergency room and have recently been in a post-acute care facility to be sent back to that facility within 30 days of discharge without considering it as a readmission to an acute care facility. It’s a win-win for everyone involved.

The goal of a hospital should be to get the patient out of the ER safely with the best possible outcome and the least risk of readmission. One way to do that is to create an internal triage diversion program in close association with the local hospitalist service provider. For example, when a potential patient arrives at the ER with a non-acute emergency, the ER physician consults with the local hospitalist service provider after the ER evaluation to quickly see the patient and determine the optimal course of action, disposition or treatment. We cannot eliminate all readmissions to hospitals, but we can make substantial inroads toward the challenge of reducing excessive readmissions.

- Felix Aguirre, MD, vice president of medical affairs, IPC The Hospitalist Company



Clinical analytics improve care coordination

Clinical analytics are the cornerstone to improving care coordination and reducing hospital readmissions. Central to any improvement initiative is the ocean of data collected in EHRs that tracks the demographic, social and medical facts about patients during their healthcare journey. Clinical informaticists comb through this data to develop actionable insights to improve patient care and outcomes. We have developed customized predictive modeling tools and budget-neutral care transition programs tailored to achieve desired outcomes.

A well-designed predictive modeling tool stratifies medical and social factors that drive readmissions and prioritizes the impactful interventions for individual patients in the population.

- Kulleni Gebreyes, MD, director, Health Industries, PwC



Leverage community collaborations

One strategy to impact the readmission rate is to form a community collaborative that brings together key players representing the continuum of care. Developing strong relationships with community agencies and long-term care providers is key to coordinate care beyond the hospital walls, educate patients and caregivers about services available in the community and address the factors that are bringing patients back to the hospital. To be successful, competition among providers must be left at the door and a collective focus must be put toward the needs of the patient.

- Pat LuCore, assistant administrator, Sacred Heart Hospital



Need exists for vertical integration of providers across the continuum

Reducing readmissions forces hospital providers to talk about proactively pursuing more vertical integrations with skilled nursing facilities, home healthcare, rehabilitation centers, primary care networks, nursing homes and other providers. More communication between providers and stakeholders across the continuum of care ultimately leads to more transparency surrounding individual facility or agency policies, practices and quality outcomes.  Increased transparency with regard to practices and quality outcomes  between providers will facilitate a greater sense of trust. This sense of trust will result in greater teamwork across the network of providers, leading to a successful outcome for patients and financial gains and savings for institutions by reducing redundant services. 

- Eric Heil, MBA, president, co-founder and CEO, RightCare



Education, education  and more patient education

Since medication compliance is a key driver of readmissions, patient and family education about medications needs to begin at the bedside and be reinforced through post-discharge phone calls made within 24 hours.

Timely follow-up provider appointments post-discharge is important to assess medication compliance and provide early intervention to disease management.

- Pat LuCore,  assistant administrator,  Sacred Heart Hospital



Support the fight against chronic disease conditions

One of the most effective ways to manage unnecessary hospital readmissions is to better manage chronic health conditions. According to the CDC, more than 80% of adults age 65 and older have at least one chronic condition, and 50% have multiple chronic conditions. It’s vital that we reform our care programs to be more preventive, holistic and personalized. When hospitalization is unavoidable, there are many elements that are critical to reducing readmission rates.Enable patients to make a rapid return to the care of their primary care physician (PCP), and employ technology solutions to streamline communications and coordinate post-hospitalization health services.

For example, assign a registered nurse to assist in the transition from hospital to home and back to the patient’s PCP of record. Work closely and proactively with PCPs, provide data and resources needed to ensure quick and timely follow-ups with patients. Provide pharmacy consultation so that patient compliance with medications and avoidance of adverse interactions are successfully managed. Even after the patient has transitioned back to the PCP, case managers should regularly connect to offer an added layer of support and personalized care to encourage treatment compliance, yield improved outcomes and assure overall patient satisfaction.

- Dirk Wales, MD, PsyD, chief medical officer, Cigna-HealthSpring



Empower patients with the right information, at the right time

Patient engagement is critical to reducing hospital admissions. After all, the more aware both the patient and healthcare provider are of how the patient is doing, the more likely it is that problems will be caught early-before they become acute.  Collection and tracking of key patient-generated data (PGD) outside of the hospital walls through remote monitoring, home health devices and personal health record application tools can be extremely useful. In addition to quantitative metrics from health devices and wearable sensors, PGD must also include subjective metrics such as reported side effects, symptoms, mood logs and exercise, diet and sleep journaling.

These observations and activities of daily living can be important indicators for how a patient is coping with their condition and their ability to manage it effectively. This is particularly important for conditions such as cancer, for which individual response to treatment can dramatically vary from person-to-person and the ability to track activities of daily living and reported symptoms and side effects can direct and change further treatment courses.

The bottom line: sharing data improves health outcomes. Engaging the patient can mean the difference between a lengthy hospital stay and a quick phone call from the doctor. 

- Cortney Nicolato, CPHIT, vice president, marketing & strategy, Get Real Health



Find solutions,  not loopholes

There are companies whose monitoring is specifically designed and validated to help hospitals reduce readmissions without resorting to gaming the system. This observation scam is going to come to a close anyway, so hospitals might as well start trying to do the right thing rather than exploit the next loophole.

- Al Lewis, executive director, Disease Management Purchasing Consortium LLC



Foster a multidisciplinary team approach  to care transition

A broad range of strategies will need to be executed to lower readmissions in the Medicare population. This includes a multidisciplinary team approach toward transitioning care to identify potential drivers of possible problems in readmissions. These include the differences in social and environmental factors experienced by patients; provision of financial and non-financial resources; internal communication and coordination; and the type of assistance with self-management of drug treatment that is available. Other factors to consider include education about potential chronic conditions that require expedited follow-up, and the creation of a patient medical record designed to bridge care.

- Michael J. Sax, PharmD, president, The Pharmacy Group


EXCLUSIVE: How to reduce readmissions>>

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