Hospital Readmission

Standardization in an Era of Personalized Care: Opportunities to Reduce Avoidable Readmissions

Abhinav Shashank
Wed 21 November 2018

Does the care process end once the patient leaves the facility? Is the definition of a doctor limited to the four walls where a patient rarely spends the 16th minute?

I could say without even thinking twice, the answer that would have come up in your mind is a clear ‘NO.’ We all can agree to this point that there has been a rise in the rate of hospital readmissions in the last few years. According to the report published by the United Health Foundation based on the source data from the Dartmouth Atlas of Health Care, the percentage of Medicare enrollees aged 65 and older who were readmitted within 30 days of hospital discharge was 14.8% in the year 2017, and is expected to rise to 14.9% by the end of year 2018.

Preventable hospital readmissions cost the American citizens billions of dollars every year. As we set our foot more firmly in the field of healthcare revolution, providers feel rising pressure on them to reduce costs and decrease unnecessary rehospitalizations. For the record, under no circumstances, providers should hesitate in readmitting patients who require inpatient care. However, a large percentage of unnecessary readmissions can be decreased by the implementation of initiatives that not just drive quality in the system but guide patients as they traverse through the care continuum.

Why the situation went out of control?

There is no one reason behind this current state. However, among many contributors, a major one could be the improper follow-up on the discharged patients. It is a general trend that when a patient leaves the care facility, it becomes quite difficult for healthcare organizations to keep track of the activities of the patient. The same situation is with the patients who are frequently transitioned to multiple care facilities.

Inefficiencies in the process of care transition of patients do not just result in a few setbacks but they are among the primary reasons behind raised hospital readmissions, frequent ED visits, and many more. As per the study published in the American Journal of Managed Care, patients who receive post-discharge care have a 28% lower risk of readmission in 30 days.

Understanding the dynamics of patients’ readmission to hospitals

The Agency for Healthcare Research and Quality (AHRQ) conducted a research to identify the percentage of 30-day readmissions that occurred within 7 days following discharge, overall and for the top 20 principal diagnoses with the highest 7-day readmission rates.

According to the finding, there were many reasons that were responsible for the patient visiting the hospitals again ranging from septicemia to chronic obstructive pulmonary disease. However, most of the conditions could have been avoided if the patients would have been properly followed-up and would have been kept under constant review.

But the main question which arises over here is how to reduce such complications? Who is the responsible stakeholder who can eliminate such situations? What strategies do we need to solve this problem?

Envisioning the right steps to guide the process of eliminating unnecessary readmissions

The coordination of care across multiple care settings is crucial for the proper implementation, management, and evaluation of a patient’s care during the entire care journey. Healthcare organizations need to identify the blind spots at every step to ease the process for the patients:

  • Understand the current ecosystem and policies

The first step for healthcare organizations is understanding the current state of their care-delivery. A proper analysis of their services, structure, patient population, the provider community, and administrative staff is required to set the groundwork for enhancing the level of care they can provide to their patients. With proper information on their reimbursement schemes and areas that need their focus, they can develop strategies to not only guide patients across the entire care continuum but also generate better revenue.

  • Identify high-risk patients

There are many circumstances and characteristics that place an individual at a higher risk of being readmitted immediately post-discharge. Hospitals need to identify the true story of every patient to make person-to-person connections to really understand what is the condition the patient is in after the discharge. This type of insight can only be obtained if we can segregate the patients based on their ailments and the probability of falling ill again.

  • Perform medication reconciliation

A research by Kilcup et. al. suggested that the patients who received a medication review and reconciliation via a pharmacist phone call post-discharge had significantly lower readmission rates at 7 days (0.8% vs. 0.4%) and 14 days (5% vs. 9%) after discharge. Medication reconciliation should be the immediate step and should remain independent on the basis of a patient visit to any inpatient care facility. It is the process of comparing patient’s medication orders to all the medications that the patient has been taking.

  • Prevent Hospital-acquired Infections

In many cases, patients take with them the reason for falling ill during the discharge from the hospital. The following categories of infections are the most prominent when we talk about hospital-acquired infections:

  1. Catheter-associated urinary tract infections,
  2. Surgical site infections,
  3. Central line-associated bloodstream infections,
  4. Ventilator-associated pneumonia, and others

Eliminating any scope of such kinds of infections should be a very important step in ensuring that every patient receives the proper care.

  • Ensure post-discharge follow-up

In the beginning, I mentioned that a hospital’s responsibility for patients’ health does not end after they leave the facility. Rather, it becomes more crucial for healthcare organizations to keep track of their patients post-discharge. Ensuring the patient’s adherence to medications, further follow-up appointments, and others need to be streamlined.

  • Building an efficient care-delivery network

The organizations should focus on building a network where providers and patients do not struggle to traverse across the care continuum. While assigning any patient to a care team member, it is important to ensure that patients know who each care team member is and what purpose they serve. Patients should not feel that they are being passed off to the person who does not have the expertise to deal with their medical problem.

  • Leverage telemonitoring facility

Hospitals can also prevent unnecessary hospital readmissions by utilizing telemonitoring technology. Patients should be promoted to participate in a program where the healthcare organization is able to keep real-time track of their activities and health conditions such as the situation of congestive heart failure patients right from their homes. Not only will it ensure that every patient is connected and tracked but will also promote the patient to actively participate in their own health care processes.

  • Empower care teams to take the right action

The value care teams add in ensuring that patients stay healthy for a long time needs no validation. From devising care plans to ensuring that they receive support at every step is the responsibility of care teams. Care teams should be well aware of the patient’s condition and that is only possible if there is proper communication between care teams and healthcare organizations. The relay of information such as the patient’s clinical data, medical history, lab results, and others should be proper and in real-time.

The success story of a Texas-based ACO

The stories of organizations who adopted the right approach and reduced their readmissions could be multiple and yet, unique in themselves. However, one inspiring one is of an ACO based out of Texas which wanted to reduce inpatient admissions with a major focus on long-term stays. The main challenges they faced were variance in the resource distribution for inpatient and outpatient services and there was a little use of analytics to anticipate patient care needs.

They worked to shift their approach from ‘episodic care’ to ‘integrated care.’ The ACO focused on every individual patient and assigned a risk score and stratified them into high-risk, low-risk, and moderate-risk, providing the ACO a higher predictive power. They leveraged advanced predictive analytics to analyze factors such as medication adherence, visit history, risk scores, among many. The ACO made sure that discharged patients got the care and attention they need to prevent unnecessary readmissions.

As a result, the ACO, with an integrated approach, was able to reduce their 30-day readmission rate by 6.74% and achieved nearly 91.3 new patient engagements per health coach per month. They were also able to reduce the number of inpatient admits for major joint replacement or
reattachment of lower extremity with MCC to 101 and average LOS to 5.9.

Tapping the true potential of social determinants of health

One thing that always remained untouched while we talked about patient readmission is considering the social determinants of health data. The quality of the place where a person lives can affect the health of a person by a great margin. According to a study, medical care determines only 20% of overall health— while social, economic, and environmental factors determine 50% of the overall health. When social determinants affect nearly 50% of the overall health outcomes, it is crucial that we consider these elements in assessing the chances of patient’s readmission.

Patient factors such as race, ethnicity, education, income, and payer have been found to be related to readmission risk in various studies. Accounting for these socio-economic factors that affect a specific patient population could be done in majorly two ways:

  • Factoring such issues to reduce or increase penalties levied on the healthcare organizations
  • Providing additional payment for the services that hospitals don’t typically get paid for, such as hiring social workers to connect patients with social services and resources that can help them avoid another hospital stay.

The road ahead

The aspects on which patient’s utilization and health outcomes are determined go beyond the conventional notions of care-delivery. Healthcare organizations need to identify the future liabilities in terms of health outcomes of a patient by leveraging predictive analytics models to prevent further chances of readmissions.

It is time that we move from the conventional approach to providing care to a data-driven approach. The time when a patient has to revisit the facility is not just the time which is lost for the patient but for the healthcare in total— time which could have been spent in treating another patient with a severe problem. It is high time that healthcare organizations move towards cutting-edge modern technological concepts such as artificial intelligence and predictive analytics. Bringing efficiency in healthcare is all about adding value to the lives of the patients. What we need now is to bring efficiency in the way we deal with the patients and a little nudge in the right direction can take us a long way, and perhaps, we could even change the perception of patients visiting the healthcare facility.


To know more about how a healthcare data platform can help you reduce your 30-day hospital readmission rates to a minimum, get a demo.

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