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EXCLUSIVE: How to reduce readmissions


Follow these suggestions to cut costs while maintaining quality of care.

Industry experts recommend technology solutions, care coordination, patient engagement and collaboration across the healthcare spectrum to reduce costly readmissions. Follow these suggestions to cut costs while maintaining quality of care. 



In most hospitals right now, caregivers work in information silos created by disparate healthcare IT systems that don’t (and in some cases, won’t) talk to each other. These silos undermine population health management efforts, stymieing patient outreach processes to activate sick patients, coordinate care and control costs. It is nearly impossible to gain meaningful visibility into performance. Hospitals that are serious about reducing patient readmissions need to invest in complete patient outreach and care coordination services which are able to fully integrate all views of the patient-from their medical records, to their referrals and downstream care, to their financials. Cloud-based platforms that provide transparency into clinical and financial information are poised to do just that.

- Jonathan Bush, CEO and President, athenahealth, Inc.


The statewide health information exchange for Rhode Island, called CurrentCare, provides an innovative way for primary care physicians and other healthcare provider teams to prevent unnecessary hospital readmissions.  The Hospital Alerts service is a critical tool for managing transitions of care, and demonstrates how real-time notifications and the resulting analytics can support the care process. 

Hospital Alerts notify providers when their patients have been admitted to or discharged from a RI hospital or emergency department, so they can quickly and appropriately follow up with medication reconciliation, after-care instructions, education and additional treatment.  We’ve observed a 15% reduction in hospital readmits for those patients whose physicians are participating in CurrentCare and subscribed to Hospital Alerts. 

Analytics plays a key role in reducing readmissions by providing insights about individual patients as well as populations, ensuring that care teams and other stakeholders get standardized, actionable, comparative, and reliable information. Analytics will be a core competency of a culture of change and improvement.  

- Laura Adams, CEO, Rhode Island Quality Institute (RIQI)



It is critical to have the right data analytics at the patient and population level to understand the problem and take action. Obviously patient-specific risk factors must be evaluated at the point-of-care to design patient-specific 30-day readmission prevention strategies, which might include a detailed discharge and medication adherence plan as well as a PCP follow-up appointment.

Equally important is the ability to look at risk-adjusted readmission trends and benchmarks at the population level to understand how readmission prevalence varies across a provider network. It could be that a system-level readmission rate is being driven by one or two outliers in terms of practice patterns, or that there are best practices within a system that risk-adjusted performance measurement will reveal. The old saying, “You can’t manage what you can’t measure,” adequately sums up the challenge of understanding and reducing readmissions.

- Matt Siegel, senior vice president, population health, Verisk Health


Data is a powerful tool available to health plans to better direct their resources. For example, the University of Arizona Health Plan has developed a system to lower readmissions by identifying patients who have had multiple readmissions-or repeated use of the emergency room-and devoted progressive, multi-tiered interventions to prevent readmissions. This ranges from ensuring a connection to a primary care provider to highly intensive case management for those with complex care needs.

Going forward, especially as people ‘churn’ on, off and among sources of health coverage, sharing such data will play a growing role in providing consistent, coordinated care and reducing readmissions.

- Margaret A. Murray, Founding CEO, ACAP


Automating the discharge process allows hospitals to enhance care team communication, engage the family in the care plan, determine a patient’s risk for readmission before discharge and implement targeted interventions that can prevent unnecessary or unavoidable readmissions and, ultimately, provide higher quality, patient-centric care to achieve more favorable outcomes.

- Josh Brewster, director of Social Services, University of Iowa Hospitals and Clinics



Care coordination


Hospitals and payers striving to reduce preventable readmissions need to remember that long-term care (LTC) communities are crucial partners in the care continuum, and they need to be proactive in aligning with accountable care organizations and other quality of care programs to help reduce risk and improve outcomes. LTC communities are eager to be included in these arrangements and are increasingly equipping their facilities with the electronic tools to ensure that the data exchange is as seamless and as mutually beneficial as possible.

- Aric Agmon, president and CEO, AOD Software



The best preventive care a hospital can provide is to keep patients out of the hospital, and the best way to do so is to thoroughly coordinate care for patients and collaborate with others in the community to better improve the quality and safety of care for every patient.

Care coordination doesn’t stop after a treatment plan or procedure is complete. We use the readmission risk assessment to determine what kind of assistance, medication, or support a patient needs upon leaving the hospital. This includes telephone calls to follow up on care, and helping to connect patients with community resources that help with transportation to future appointments, medication pick-up reminders and one-on-one consults with pharmacists to ensure proper medication adherence. By deploying coordinated strategies and best practices system wide, we can better ensure procedures are conducted as routinely and as safely as possible. By actively participating in each step of the patient journey, we can avoid unnecessary readmissions, and get closer to our overall goal of reducing readmissions by 20% before 2015.

As an industry, we must remain committed to culling expertise across health systems and networks, sharing resources and best practices, collaborating with other networks, sharing our successes, learning from others and adapting evidence-based practices and technologies.

-Barbara Pelletreau, senior vice president, patient safety, Dignity Health




Medicare penalties associated with preventable readmissions pose significant financial risk to a hospital’s bottom line. At issue is the ability to successfully coordinate care once the patient is discharged, including electronically coordinating discharge orders, referrals and follow-up appointments, as well as analytics to track patient engagement and instruction compliance, clinical workflow and outcomes. Hospitals finding themselves losing valuable reimbursement revenue due to readmissions penalties need to be more proactive about their compliance strategies, including optimizing post-acute care and patient discharge management.

- Joel French , CEO, SCI Solutions



The hospitalization cycle is difficult to impact and presents many challenges. To address these challenges we convened a task force of care management leaders from across the network and charged this team with assessing barriers to successful transitions of care and developing system-level strategies to diminish those barriers. As a result, the task force developed recommendations for the network around four categories: follow-up care, discharge planning, patient teach back-a process asking a patient to repeat back in their own words what they need to know or do-and medication reconciliation.

These unique and evidence-based recommendations have been implemented in our network and have increased the quality of care for our members through improved care coordination both in and out of care management.

- Sarah Fowler, MSN, GNP-BC, director of Medicare Preferred Care Management, Tufts Health Plan



Patient engagement


The truth is that many of the Medicare patients who are readmitted to the hospital within 30 days could stay clear of readmission if health systems implemented better population health monitoring and patient engagement efforts. Under this scenario, the sickest patients would be activated early for preventive care and treated to a red-carpet experience. Their progress would be charted across the care continuum, and they’d be coached and consulted through care management programs. This would ensure that resources are directed to the sickest patients and their care transitions, and in turn, would improve quality and contain costs-often in less costly outpatient settings.

- Jonathan Bush, CEO and President, athenahealth, Inc.


Observation status has been used in healthcare for decades; however, hospitals have recently been overusing observation status as a means for reducing readmissions. Complying with any healthcare regulation should not be about meeting requirements strictly out of technicality. It should be about improving patient safety and keeping the patient’s needs and interests at the center of care. To effectively reduce readmissions, hospitals need to look beyond the semantics of possible legislation and employ more patient-focused methods.

Engage the family starting at admission: For most diagnoses, hospitals know approximately when patients will be discharged and can use this information to begin planning the patient’s discharge with the family as early as the time of admission-rather than waiting until the day before discharge. Giving families more time to choose discharge plans will ensure patients continue to receive the care they need and will reduce readmissions.

Communicate more than just clinical information: While EHRs and HIEs have been instrumental in sharing clinical information, the provider needs to understand more than the medical aspects of a patient’s health to ensure he or she gets the care they need. For example, providers should understand whether a patient tends to skip follow-up appointments because they lack transportation or if they have a history of not talking their medication. Care process information is integral to recommending interventions and preventing readmissions.

Facilitate care transitions with non-medical providers: Coordinating with other providers, while important, is only one piece of the care transition puzzle. To effectively facilitate care transitions, hospitals may need to reach beyond traditional medical providers to make sure patients and post-acute care organizations have all the resources they need to execute care plans. By leveraging automated technology solutions, providers can reach out to non-clinical providers to supply transportation, deliveries, cleaning and other services as an effective way to fill care gaps.

- Wayne Sensor, CEO, Ensocare




Specialty pharmacies, with the right plan in place, can play a role in minimizing hospital readmissions. As a specialized interventional pharmacy, our pharmacist team works with patients facing both chronic and complex disease treatment. Patients who are not fully compliant with a treatment plan can drive up already high treatment costs. We have found that increasing patient adherence controls treatment costs in the long run, while maximizing patient outcomes. Reducing readmissions can be a significant part of adherence-related savings.

- Russell Gay, chief strategic officer, BioPlus Specialty Pharmacy


Payer/provider collaboration


Payers and hospitals can work collaboratively to align forces and implement programs aimed toward improvements in discharge planning, which can contribute to decreased readmissions. By leveraging the data that payers have about the member (of past history, successful past plans, risks, etc.) as well as the experience in working with multiple facilities and levels of care, positions the payer to be an important contributor as part of the discharge planning process. Hospitals and payers need to develop methods to encourage this collaborative effort. Close follow-up after discharge with appropriate communication of information to treating providers.

- Paula M. Sauer, senior vice president, Pharmacy Care Management, Medical Mutual of Ohio


Sending a patient who might otherwise be considered a “readmission” to an observation bed does not address the underlying issue. One way the insurance and hospital industries can work together is by creating consensus and consistency around the definition of readmissions and the metrics used for creating incentives and disincentives for readmissions based on mutually agreed upon evidence-based medicine criteria. In addition, the two industries should work to find ways to better incorporate the transfer of information between health plan care coordinators and providers’ medical records to help ensure that timely, accurate information is being exchanged during the critical time period following discharge from a hospital or facility.

- Martin P. Hauser, president and CEO, SummaCare, Inc. 

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