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Reduce readmissions by focusing on better engagement with patients and improving coordination from inpatient to outpatient settings.
In an era where high healthcare costs are frequently blamed on expensive drugs and high administrative overhead, the importance of reducing hospital readmissions to improve health outcomes and lower costs has become less of an area of focus of late. That’s unfortunate as recent estimates from the Medicare Payment Advisory Commission found that 75% of readmissions could have been prevented with better care coordination, saving Medicare alone an estimated $12 billion in excess spending. That doesn’t even account for the costs of hospital readmissions to Medicaid, the Veterans Administration, and private payers.
There are effective solutions to this unnecessary financial drain. To reduce readmissions, we must focus on better engagement with our patients and improved coordination from inpatient to outpatient settings. By taking a patient-centric approach before, during, and after a discharge, we can better ensure a patient (and/or caregiver) is fully informed on best practices related to his/her well-being immediately post-discharge when they are most vulnerable. This level of engagement requires a greater emphasis and investment on patient communication, coordination, and connectivity across the healthcare continuum, with the goal of driving fewer readmissions and reduced healthcare costs.
Let’s imagine a patient is in the hospital after having just gone through what has most likely been a very traumatic health event. They are frequently distressed, exhausted, emotional, and quite vulnerable. Typically, their main concern is that they want to go home, and their ability to comprehend the various instructions of various healthcare providers in the hospital setting is likely to be highly diminished. Discharge nurses and physicians must acknowledge this fact, and understand that proper handoffs from inpatient to the outpatient care coordination team are essential to driving safer and higher quality care transitions. Ensuring that the patient understands all the information related to their condition and treatment is instrumental in beginning the path to a healthy recovery.
Once patients are discharged, it’s critical to deploy support mechanisms that are built around the whole patient, taking into consideration past health history, preferences, lifestyle, and discharge plan. One example is having prompt and thorough follow-up once a patient has settled back into their home to ensure that they are fully aware of their new medication regimen, the reason for any new prescriptions, and the importance of treatment adherence. Processes should be in place to ensure that patients promptly fill discharge prescriptions and that these new prescriptions do not conflict with any medications (prescription or OTC) that patients may already have been taking prior to admission.
Having a properly trained nurse or pharmacist conduct proactive outreach and intervention with the patient or caregiver can help ensure more effective adherence, and appropriate usage. Additionally, having clinicians available on-call immediately after discharge, when patients are most susceptible to event recurrence or adverse effects, is an important way to provide patients and caregivers with the reassurances they need by quickly answering questions and concerns. In more high-risk scenarios, a home visit by a clinician can further help ease the transition after a long hospital stay, set a precedent for prolonged health, and increase the likelihood of adherence to better care.
Digital tools are also helpful in promoting proper education and adherence. These tools include interactive condition-specific web forums, educational briefings, or live video chats that provide access to support and counseling. Home monitoring tools, such as digital scales for patients being discharged after heart failure admission, can also help closely monitor health results that may indicate the need for prompt clinical intervention. Such connectivity ensures that essential information is readily available to the patient, caregiver and provider.
Monitoring for proper drug compliance is also critical. Nonadherence-whether in the form of a patient never filling a prescription, or a patient failing to maintain consistent daily use of their medications-requires very close monitoring and intervention in the post-discharge setting. Nonadherence occurs for a variety of reasons, often due to a lack of information or lack of proper post-discharge assessment. An open line of communication between the patient and physician; proactive calls to gauge a patient’s health state; and monitoring vitals like nutrition, weight, or blood pressure will help encourage adherence and lead to improved care.
Several companies and programs have recently made remarkable strides in reducing readmissions through patient engagement. Dovetail Health, an Optum company based in Waltham, MA, offers a hands-on approach by identifying high-risk patients who are more likely to be readmitted, and closely supporting them after initial discharge, resulting in an increased quality of care. Dovetail uses data and analytics to pinpoint potential care gaps to determine which patients have a higher need for intervention. From there, Dovetail takes the extra step by sending a clinician to bring personalized care into the home, making patients more confident about taking an active role in managing their health.
Providing care in the patient’s home is the ideal setting for patients with complex needs at high risk of utilization. Meeting the patient in comfortable surroundings, where the patient may be more forthcoming about the challenges and barriers to appropriate medication taking behavior allows the clinician to assess the way the patient organizes their medications and their capacity to manage their medications in a way that is limited over the phone or in an office setting.
As the U.S. population continues to age, the healthcare industry faces increasing clinical and economic pressures. We need to properly balance efforts to drive out avoidable healthcare costs while sustaining the highest possible level of quality and service. Doing so requires us to rethink the way we communicate and coordinate across our complex healthcare system and more importantly, how we engage with patients and caregivers. In the area of hospital discharges, we must work hard to leverage the enormous power of healthcare IT, data, and communication tools to strengthen our commitment to reducing readmissions, putting the patient first, and unlocking the full potential of our country’s healthcare capabilities.
David Calabrese, RPh, MHP, is senior vice president and chief pharmacy officer of OptumRx. He also is an editorial advisor for Managed Healthcare Executive.