Reducing Readmissions: A Better Way

Posted by Kyle Salem, Ph.D. on 5/19/14 10:14 AM

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Did you know that nearly 80 percent of serious medical errors involve miscommunication during patient transfers? Doesn’t that illustrate the need for accurate and timely information exchange in discharge planning?

There’s got to be a better way—one that benefits patients and providers.

Hospitals are employing nontraditional best practices to improve communication and avoid penalties. Consider the following strategies many facilities use to support robust patient care across the continuum.

Technology can streamline discharge planning to ensure that vital information follows patients.Communicate more than clinical information
Clinical information alone may not be enough for a patient, family and post-acute provider to understand how to keep a patient healthy. Families and providers need to “get” the processes necessary to ensure the patient receives the care she needs.

For instance, a post-acute provider might know a patient’s medical history, medications and follow-up appointments. But the provider may not know the patient has a history of medication noncompliance and skipping follow-up appointments because he has no transportation. Without communicating these issues, the hospital puts the patient at substantially higher risk for readmission.

Expand reach outside the medical world
Patients with diabetes or congestive heart failure may have specific nutritional needs they cannot meet on their own, requiring in-home assistance with meal preparation or shopping provided by a home care organization.

Some hospitals are coordinating essential, nonmedical resources to ensure patients follow their care plans completely.

Use technology to manage large patient populations and maximize staffing resources
To manage discharge for a large patient population, hospitals stratify patients by risk, including risk for readmissions. Many electronic health records stratify risk based on conditions at admission, assuming care at the hospital or following discharge has no effect on readmission risk. But hospitals should employ additional technology that provides a holistic view, and recalculates readmission risk at discharge and different stages throughout the patient’s recovery.

For instance, a patient who misses an appointment 72 hours after discharge should be at higher risk for readmission than a patient with a similar diagnosis who attends the appointment. By identifying patients whose risks are increasing during post-acute care, providers are able to manage more patients.

Through risk stratification, hospitals can also direct highly technical, low-touch interventions to low criticality patients, while aiming low-tech, high-touch staff resources at higher criticality patients.

Consider a 25-year-old woman being discharged from the hospital, expected to make a full recovery and going home to a family. The hospital has identified her as low risk. By leveraging an automated discharge process or using technology like texting, the hospital can engage the patient without consuming staff resources. Conversely, a 90-year-old high criticality patient with little family involvement, transferred to a skilled nursing facility, won’t respond to high-tech, low touch solutions. The best way to reach him is direct staff intervention.

By employing technology that maximizes resources and streamlines communication during transition, hospitals can ensure that vital information and practical process suggestions follow patients throughout their care journeys.

One Solution
An IT solution backed by customer service resources that can coordinate care across all care settings is the most effective way to manage cost outcomes and patient outcomes. I invite you to learn more about Ensocare for your hospital, accountable care organization or ambulatory surgery center.

Topics: Post-acute Care, Care Coordination, Reducing Readmissions