Optimizing Care Transitions: A Key Strategy for Reducing Readmissions

The following sections offer a roadmap of how to re-envision care transitions to increase their reliability and mitigate risk

Last year, the Centers for Medicare & Medicaid Services (CMS) withheld a collective $420 million in reimbursements from half of the nation’s hospitals due to readmission penalties. As CMS continues adding condition- and procedure-specific regulations through its Hospital Readmissions Reduction Program (HRRP), associated penalties will also increase, placing even more financial risk onto providers. If organizations don’t get a handle on how to limit readmissions, the financial impact alone will be substantial — not to mention how patients will perceive the quality of care organizations deliver.

Improving care transitions to prevent readmissions

It is estimated that as many as 75% of Medicare readmissions are avoidable, causing a great deal of unnecessary spending. In fact, according to the National Learning Consortium, approximately $44 billion in wasteful healthcare spending is attributable to unplanned hospital readmissions.

A significant root cause is poor care transitions between hospitals and post-acute settings, such as skilled nursing facilities, rehabilitation programs and home health care. Traditionally, the hospital discharge process has been fraught with communication breakdowns and poor information exchange, which cannot only yield less-than-ideal outcomes but can increase the likelihood a patient will return to the hospital.

However, when organizations take a more systematic approach, they are able to improve workflow, limit communication lapses and address other challenges. Such an approach includes a few essential components.

Target At-Risk Patients

As early as admission, hospitals can begin identifying individuals at risk for readmission based on clinical, social and financial factors, including the patient’s condition, health history, family support and more. A 75-year-old woman undergoing total hip replacement with a strong family support system who historically follows her care plan will tend to have a lower readmission risk than someone with no home support and a history of poor care plan adherence.

By identifying concerning factors early, hospitals can proactively address them when coordinating a post-acute transition. Perhaps the hospital will make additional follow-up calls to the high-risk patient, arrange for a nursing service to periodically visit the individual or use mobile applications to stay in contact with the patient and family over a period of time. By proactively stratifying and mitigating risk, organizations can effectively allocate resources and focus their attention on patients who need it most.

Ensure Appropriate Post-Acute Placement

In some hospitals, patients and their families aren’t given much time, information or guidance to select a post-acute provider when one is necessary. However, this placement could potentially mean the difference between a positive outcome and an unplanned trip to the hospital. Finding the right facility that not only accepts the patient but also meets all of his or her clinical and psychosocial requirements is key.

For instance, if a patient recovering from a stroke requires physical, occupational and speech therapies multiple times per week, the post-acute care facility must be able to meet all of these needs. Otherwise, the patient may have to be transferred to another location or return to the hospital, potentially causing upheaval for the patient and financial consequences for the hospital.

Manually searching for appropriate facilities is labor-intensive, time consuming and may still not yield the best fit. Rather than calling individual locations, hospitals that use care coordination technology can generate a customized request based on the patient’s clinical and psychosocial needs and share that request with surrounding post-acute providers simultaneously, obtaining responses in minutes rather than hours—or even days. Hospitals can then share this well-vetted list with the patient and his or her family, helping them make a more informed choice surrounding the next stage of care. Leveraging technology in this manner can expedite the post-acute placement process while ensuring the patient finds the most suitable match.

Hospitals can also use care coordination technology when trying to identify additional services for patients who are ready to be discharged home. Consider the person who lacks transportation and yet is expected to pick up his or her prescriptions, attend appointments and purchase groceries. Without addressing the underlying need for transportation, the hospital increases the risk the patient will not follow his or her care plan and thus elevates the likelihood of readmission. Hospitals can use technology to match patients with necessary services—transportation, housekeeping and meal delivery—thus better preparing individuals to navigate the post-discharge environment.

Facilitate Robust Information Exchange

The traditional process for sharing information between hospitals and post-acute care organizations is sending all or a large portion of the patient’s medical record to the receiving facility. Although this process has become more streamlined since hospitals started using electronic health records (EHR), most organizations still share more information than is needed, and sometimes it does not arrive in a timely fashion.

However, using automated care coordination tools, hospitals can share the most relevant information directly from the EHR, ensuring receiving clinicians have all the information they need to support care quality and continuity—and the data arrives in an easily digestible form. By receiving this information prior to the patient’s arrival, post-acute care providers are able to prepare prescription and therapy orders in advance to prevent any delays or gaps in care.

Stay in Contact with Patients and Families

Historically, once a patient was discharged, the hospital would lose track of the individual, moving on to new patients and new priorities. However, now that hospitals are responsible for patient outcomes for 90 days post discharge, it is in their best interest to identify ways to stay in touch. Hospitals can leverage care coordination technology to virtually follow patients in post-acute settings. Such solutions allow the organization to continue stratifying patients and adjusting their readmission risk as they progress through their care plans. For patients who transition home, hospitals can use solutions that rely on mobile apps and electronic messaging to ensure patients adhere to their care plans. For instance, if patients miss appointments, fail to meet milestones or neglect to fill prescriptions, the technology will notify the hospital and other care team members, allowing them to intervene accordingly.

Technology Plays an Essential Role

As can be seen in the previous strategies, a strong technology infrastructure can facilitate safer and more consistent care transitions. By using automated solutions, organizations can improve both the efficiency and reliability of these high-risk times. According to CMS, “Gaps and duplication in service delivery can be reduced or eliminated through the use of technologies,” and the agency encourages organizations to collaborate using these kinds of solutions.

In a time when hospitals are facing ever-increasing financial risk and responsibilities, harnessing care coordination technology can enhance the discharge process, ultimately reducing the chances for readmission.

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