How payers can help hospitals reduce readmissions

Preventing hospital readmissions must be top of mind for payers and providers, says Jill Duncan, RN, executive director at the Institute for Healthcare Improvement, where she leads the Joint Replacement Learning Community.

The best way to reduce readmissions is to focus on providing care at the right place and at the right time, she says. “Keeping patients out of the hospital reserves space for those who need it most. For patients [with less acute needs], receiving care in a supportive environment is a better fit.”

DuncanDuncan is particularly excited about a payer-provider collaboration she learned about at IHI’s Total Joint Replacement Collaborative, a program for provider organizations that perform joint replacement procedures. While Duncan can’t share the names of the provider or payer involved in the project, she says the collaboration involved securing reimbursement for “pre-hab,” which involves having occupational therapists and physical therapists evaluate patients before their total joint replacement surgeries.

Because the payer was willing to reimburse for the physical therapist and occupational therapist before the surgery, the providers were able to evaluate patients during their presurgery teaching clinic as well as in their own homes to determine what patients needed to get patients to their outpatient rehabilitation.

The information gathering in patients’ homes included counting the number of steps between their driveway and their front door, how many stairs they had in their homes, what kind of car they drove, and what sort of support structure they had, says Duncan.

“This work really showed a tremendous reduction in patients’ length of stay, an increase in patients being discharged to their homes instead of residential rehabilitation facilities, and [a decrease in] their readmissions rates. All of that has a huge impact on the cost to the provider and the cost to the payer.”

While payers and providers should be focused on reducing readmissions, Duncan says taking a hard look at why patients are readmitted to the hospital also requires understanding patients and their needs, even before they come into the hospital. That requires payers and providers to get to know the communities they serve and learning about the types of supports that are available in the community.

For example, she cited EMS services that are starting to build up the capacity to check in on elderly patients who have come home from the hospital and may have mobility issues that make getting to follow-up appointments challenging. 

Aine Cryts is a writer based in Boston.