Preventing Hospital Readmissions Through Post-Discharge Care Management

By Health Ideas Staff
Nov. 26, 2019

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Prior to the establishment of the Hospital Readmissions Reduction Program (HRRP) as part of the Affordable Care Act, a study published in the New England Journal of Medicine found that nearly 20 percent of Medicare fee-for-service beneficiaries were readmitted into the hospital within 30 days of being discharged. According to the Agency for Healthcare Research and Quality (AHRQ), readmissions were responsible for $41.3 billion in total hospital costs in 2011.

The HRRP, which reduces payments to hospitals with excessive 30-day readmissions, represented a significant step in incentivizing better care coordination around the post-discharge process to keep at-risk patients healthy and out of the hospital. CMS reported that from 2010 to 2015, preventable hospital readmissions declined by 8 percent nationally.

Though well-intentioned, concerns have long been raised that the program places certain institutions — particularly, safety net hospitals serving vulnerable patient populations — at an inherent disadvantage. For these providers especially, identifying patients at a high risk of readmission, and implementing a post-discharge strategy that effectively mitigates that risk, requires a comprehensive assessment of the person’s medical, behavioral, socioeconomic and even emotional needs in order to address the root cause.

Reducing hospital readmissions among high-risk populations is a complex endeavor that requires a 360-degree approach to understand, engage and support patients throughout their entire healthcare journey, of which post-acute care management is a vital component. Here are three key areas of focus to help patients stay healthy beyond the inpatient setting.

Understand Not Just the What, But the Why
With approximately 30 to 50 percent of all ED visits in the US considered to be non-urgent, understanding why exactly an individual sought emergency care in the first place is essential to determining the likelihood of readmission. If the patient ended up in the ED for a non-acute event, was it due to a lack of knowledge about where to go in a non-emergency? Could it have been the result of an SDoH factor, such as food or housing insecurity?

Digging deeper to understand the full scope of factors that led to a hospital visit, from the medical condition itself to the patient’s understanding of how to interact with the healthcare system, will allow you to better assess the risk of readmission and develop a transitional post-care strategy that ensures the right care from the right source.

Be Proactive in Your Outreach & Strategic in Your Communications
An effective healthcare engagement strategy rests on a deep understanding of the person with whom you’re communicating and uses that knowledge to adapt messages to achieve the defined objective — in this case, ensuring patients are equipped to manage their health following a major event or procedure. And as healthcare becomes increasingly focused on the needs of the whole person, your post-discharge follow-up strategy should be equally comprehensive.

Reaching out in a timely manner — within 48 hours of discharge — will not only allow you to deliver critical health information, but also open up the conversation to gauge how the person is really doing, identify risk and intervene to prevent a readmission or worse outcome. While the health event may have been the initial trigger, there are a number of other factors that can influence another, including:

  • The patient’s involvement in the discharge process and understanding of discharge instructions
  • Knowing when and where to visit a primary care provider or urgent care center
  • Availability of caregiver resources
  • Medication compliance
  • Mental health status, lifestyle and overall well-being

A recent study published in the journal Heart found that older heart patients who reported feeling lonely were at a higher risk of dying within a year after hospitalization, suggesting that loneliness should be considered a serious risk factor among this population. This is just one example of how seeing beyond the patient’s condition to the needs and vulnerabilities of the person is critical to providing appropriate post-acute care and long-term support.

Make It a Combined, Ongoing Effort
Research published in the International Journal of Environmental Research and Public Health studied the effectiveness of various interventions in promoting early hospital discharge and avoiding readmissions, finding multidisciplinary approaches employed pre- and post-discharge to be most effective.

With hospital readmissions serving as a key quality metric of performance and value-based care models, care teams must work together to ensure the long-term needs of patients and members are being effectively managed. Population Health Management (PHM) platforms that facilitate an integrated care approach and engage members in their health decisions are helping to address the issue of avoidable hospital readmissions and various other inefficiencies that drive up healthcare costs and prevent access to quality care.

Get Involved
Recognizing that the collaboration of industry, academia and government is the key to solving healthcare’s most pressing issues, HMS has partnered with the Digital Health Cooperative Research Centre (DHCRC), the largest digital healthcare research center in the world. Among DHCRC’s active initiatives is the Readmissions Avoidance Project, a collaboration with Southern Methodist University to identify and prevent causes of avoidable readmissions. By researching specific patient care and engagement practices at discharge, the project aims to identify those that result in better outcomes and reduced readmissions.

Healthcare organizations that help advance DHCRC research by permitting use of their de-identified claims data gain access to this research as well as related tools for PHM purposes. To learn more about DHCRC and the Readmissions Avoidance Project, or to join HMS in advancing this initiative, visit the DHCRC resource page.

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