Reducing Readmissions After Post-Acute Care

Published May 9, 2016

Today, too many patients return to the hospital after getting discharged – driving up costs, worsening outcomes, and discouraging the patient.

If you or a loved one has ever come home from the hospital, you know the challenge of transitioning to home life. Managing medications, providing support, and scheduling care can overwhelm the caregiver. This becomes an even greater challenge if the patient lacks family support, faces transportation issues, or has difficulty communicating or comprehending the complexity of their condition.

Preventing readmissions is not easy. Of the 3,400 eligible hospitals in the most recent CMS Hospital Readmissions Reduction Program, only 799 (23%) reduced readmissions sufficiently to avoid a penalty.

Furthermore, a study of discharged patients revealed:

  • More than 30% of patients were on 8 or more medications
  • 69% had been prescribed a new medication at discharge
  • Over 40% didn’t understand the medication side-effects
  • The majority had 3-4 services prescribed post-discharge
  • Many had an incomplete understanding of their disease

This is an opportune time to re-think the traditional approach to post-acute transition – transitions that can take anywhere from 30 to 90 days with complex cases. Even if patients have access to home healthcare, there is often a missing link – a missing command post to manage the complex transition from hospitalization to home and to fill the gaps between fragmented services.

What would a post-acute command post look like? How would it integrate the pieces and parts of the patient’s post-acute journey?

At a minimum, an integrated approach would include:

  • A single-point-of-contact care team to serve as the command post
  • Management and coordination of providers and services as needed by the patient
  • Highly skilled transition coaching to support the patient telephonically and in person
  • Data analytics for patient stratification according to medical risk and site of care selection
  • High performing networks of post-acute care providers who are preauthorized for quality and connectedness
  • A technology platform to connect the patient, caregiver and providers to each other at every step

Looking across the medical cost management landscape, reducing readmissions is one of the most powerful and still untapped ways to reduce costs and improve post-acute outcomes. Today, initiatives are underway to integrate the people, processes, and technology involved in post-acute care in new ways. These efforts will allow patients with ever-more complex conditions to successfully transition from the hospital and heal in the comfortable surroundings of home.