Beating Readmission – Today and Tomorrow

When someone leaves the hospital, the last thing they or their caregivers want to imagine is that they’ll be back in less than a month.

Despite the fact that physicians and nurses work hard to prepare patients and their families for a successful transition from the hospital, unplanned readmissions remain a major challenge for the U.S. healthcare system. Indeed, 1 in every 5 elderly patients is readmitted within 30 days of going home.

Part of the problem with tackling unplanned readmissions is that the causes are so varied, including complex combinations of medical complications, socio-demographic factors, and access issues.

Put simply, when it comes to unplanned hospital readmissions, every story is different. To illustrate the challenge – and how technology is helping address it – we’ll look at just two:


Bill’s Story

Bill is 66. He’s a Medicare client, with a pacemaker. He often experiences chest pains, and lives in constant fear of further problems with his heart.

When Bill feels pain or discomfort, he panics and gets his neighbor to drive him to the hospital.

Bill’s family lives out of town. They’ve learned to share Bill’s fear, and as a result, have stopped inviting him to visit. They’re concerned he’ll be too far from the hospital when chest pains strike.

This makes Bill feel more isolated ­– compounding his fears, and making his visits to the hospital more frequent.


Annie’s Story

Annie is 54. She suffers from multiple chronic diseases, isn’t eligible for Medicaid or Medicare, and doesn’t have insurance to pay to see a doctor.

As a result, she frequently goes to the hospital emergency department to see a doctor, get her medications and treat episodic flare-ups.


The Consequences

Not only are Bill and Annie’s frequent visits to the hospital expensive, they aren’t receiving the continuity of care that people with chronic disease often need. More cost-effective care from a consistent primary care provider could help them better manage their healthcare needs, and improve their quality of life.


Fighting Readmission Effectively

The causes and stories might be different every time, but increasingly, hospital readmission reduction programs are moving towards common tactics in addressing unnecessary and unplanned readmissions more effectively. Here are four:

Listening to the Data

Today, healthcare data analytics help providers assess the risk of readmission and plan more effective discharge plans and follow up services. In the near future, discharge apps and monitoring devices will play an increasing role in preventing unplanned readmissions, by allowing patients to communicate with their care providers, and ensuring more timely treatment that could prevent another trip to the hospital.

Favoring Collaboration

Readmissions are often the result of ‘silos of care’ that prevent healthcare providers from understanding the underlying root causes of a patient’s return to the hospital.

Opening the channels of communication and collaboration between care management, payers, providers and community resources makes it possible to identify – and act on – the best strategies. Access to a shared electronic medical record (EMR) can improve continuity of care, while clinical surveillance and automated alerts derived from the EMR data can help providers identify and respond to the complex factors that place patients at risk for readmissions.

Looking at Social Determinants

Often, the underlying causes of unplanned readmissions have less to do with health issues and more to do with social issues such as housing, nutrition and substance abuse.

By spotting these social causes and including them in care plans, healthcare providers can deploy low-cost, high-impact programs that deflect ineffective uses of emergency departments and hospitals.

Involving Patients in Care Management

Patient-centered care management is another crucial part of the puzzle. Evidence-based models – such as Coleman Care Transitions Intervention – encourage patients to take a more active role in their healthcare, and provide additional resources and support after patients are discharged. These have the potential to help tackle hospital readmissions, while improving patient care experiences.

The Care and Quality Solutions (CQS) team at Conduent implemented a variation of this model for a U.S. client. Since then, the client has seen its 30-day readmission rates decrease from about 7.6 percent in 2011 to 6.4 percent. Nationally, the Medicaid readmission rate is about 12.5 percent.


Better Outcomes for Bill and Annie

When data, collaboration, social determinants and patient-involved care come together, there’s a real possibility for better outcomes, fewer readmissions and lower cost of care. Here’s how Bill and Annie’s stories can play out:

Using healthcare analytics on hospital claims data, Bill and Annie’s local providers identify them as frequent utilizers of emergency care services and candidates for specific attention.

The Care Manager at Bill’s local hospital coordinates with the Developmental Disabilities case manager, and contacts providers and community resources, including Bill’s family and his cardiologist.

Bill now receives a thorough assessment, with heart studies to ensure he’s not in danger of a heart attack and provide peace of mind. Moreover, a collaborative health resource plan is put in place while Bill and his family are educated about his condition.

Bill doesn’t visit the emergency department once in the next year, and enjoys a more comfortable, less fearful life, traveling out to see his family almost every weekend.

Annie’s providers conduct a root-cause analysis to understand the historical patterns in her frequent hospital visits. They quickly realize she lacks a primary care provider.

One of the part-time Emergency Medicine doctors who had treated Annie on several occasions, also happened to operate a Family Practice. He agrees to become Annie’s primary care provider. Annie agrees to a small co-pay for her visits with her new doctor, and the hospital agrees to reimburse him for the remaining costs as an alternative to providing more costly care in the emergency department.

The result is better for everyone. Annie gets better care and costly hospital visits drop dramatically.


Moving in the Right Direction…

Stories like these are becoming more common across US hospitals.

The Centers for Medicaid and Medicare Services (CMS) introduced public reporting for hospital readmissions in 2009, followed by a Hospital Readmission Reduction Program in 2012, which imposes financial penalties for hospitals with “excess” unplanned readmissions.

Beginning in October, 2017 CMS will begin public reporting of a new set of measures that examine the number of ‘excess days’ following discharge from the hospital. This measure looks at the number of days patients spend on emergency department visits and hospitalizations following discharge from heart attack or heart failure. It’s likely financial penalties for excess days will be imposed on hospitals in the years ahead.

The CMS’s strong focus on the issue has helped put unplanned readmissions on a downward trend across most U.S. hospitals – but there’s still a long way to go to better assist hospital providers in doing the right thing, at the right time and in the right place. MidasPlus, Inc., a Conduent company, is helping hospitals measure, monitor and manage their patients through care management workflow tools, predictive analytics and risk stratification of high risk patients.

To learn more about how Midas is helping providers to cut readmission rates, click here.


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