Health plans have partnered with provider organizations for years to collaboratively reduce avoidable hospitalizations and reduce readmissions. Many have learned that preventing readmissions is not easy.
Why do readmissions remain such a problem? One key driver is the lack of coordination of care after discharge and the fragmentation of our health delivery system. Once a patient is discharged to a Skilled Nursing Facility (SNF) for rehabilitation, or to home, the integration of services and support is often missing at a time when the patient is making a critical transition.
Home-centered services play an increasingly important role in successful transitions because they can reduce costs and increase member satisfaction. But home services alone don’t address the challenge of transitions. What’s needed is an integrated approach – one that involves transition coaching, coordination of services, close communication and coordination among stakeholders, and dedicated technology to integrate people and processes.
This white paper covers:
- Identifying the best path for the patient’s care after discharge and understanding the costs dependent on setting for care
- Engaging the highest-performance providers and selecting the right partners for post-acute care through network evaluation
- Identifying patients most at-risk for readmission and support interventions by remote patient monitoring for high-risk patients
- Connecting patients, providers, and caregivers through care coordination, care management and the use of new technology platforms
- A personal story on the impact of transition coaching