Tag Archives: readmission

Improving Transitional Care Management to Reduce Hospital Readmissions

Hospital readmissions have become a critical issue in healthcare, significantly impacting patient outcomes and increasing healthcare costs. In response, Transitional Care Management (TCM) programs have emerged as a vital strategy to ensure that patients experience smooth transitions from hospital to home or other care settings, thereby reducing the risk of readmissions. This blog explores the importance of TCM programs in preventing hospital readmissions, improving patient outcomes, and creating a more cost-effective healthcare system.

The Challenge of Hospital Readmissions

Hospital readmissions occur when a patient who has been discharged from a hospital is readmitted within a short period, usually within 30 days. According to the Centers for Medicare & Medicaid Services (CMS), nearly 20% of Medicare patients are readmitted within 30 days of discharge, costing the healthcare system approximately $26 billion annually, with $17 billion of that amount deemed preventable.

Readmissions are often caused by a lack of adequate follow-up care, poor coordination between healthcare providers, and insufficient patient education. These gaps in care are particularly problematic for patients with chronic conditions, who are at higher risk of complications post-discharge. As a result, healthcare systems are looking for ways to close these gaps and enhance post-discharge care.

The Role of Transitional Care Management in Reducing Readmissions

Transitional Care Management (TCM) is designed to fill the gaps in care following a patient’s discharge from the hospital. The primary goal of TCM is to ensure that patients receive timely follow-up care, which helps to prevent complications, reduce the likelihood of readmission, and improve overall outcomes. TCM services typically include:

  1. Post-discharge Communication: TCM programs emphasize timely follow-up with patients after discharge. Within two business days, a healthcare provider should reach out to the patient to assess their condition, answer questions, and provide further instructions.
  2. Face-to-face Visits: Within 7-14 days, patients are scheduled for a follow-up visit to evaluate their recovery progress, review medications, and address any new or existing health concerns. This visit is critical to identifying potential issues early, preventing complications, and ensuring patients adhere to their post-discharge care plan.
  3. Care Coordination: TCM programs aim to improve communication and coordination between different healthcare providers involved in the patient’s care, including primary care physicians, specialists, home health services, and pharmacists. This coordination ensures that all providers are on the same page, preventing fragmented care that can lead to readmissions.
  4. Patient and Caregiver Education: Educating patients and caregivers about the patient’s condition, medications, follow-up care, and warning signs of potential complications is vital to successful recovery. TCM services offer ongoing education to empower patients to manage their health post-discharge effectively.
  5. Medication Management: Adverse drug events are a common cause of readmissions. TCM programs focus on reviewing patients’ medications during follow-up visits, addressing potential drug interactions, ensuring adherence to prescriptions, and adjusting medication plans as needed.

The Impact of Transitional Care on Patient Outcomes

Studies show that TCM programs significantly reduce the likelihood of hospital readmissions. Research published in the Journal of General Internal Medicine found that Medicare patients enrolled in TCM programs experienced a 13% reduction in readmissions compared to patients who did not receive these services. Another study published in Health Affairs reported a 20% decrease in 30-day readmissions for patients receiving high-quality transitional care.

Beyond reducing readmissions, TCM programs also contribute to better patient outcomes by:

  • Improving continuity of care: With better coordination between providers and regular follow-up, patients are more likely to receive the care they need in a timely manner.
  • Enhancing patient satisfaction: TCM services provide personalized attention and clear communication, which improve the patient experience and lead to higher satisfaction rates.
  • Reducing healthcare costs: Fewer readmissions result in lower healthcare costs, benefiting both the healthcare system and patients.

Key Strategies for Effective Transitional Care Management

To maximize the effectiveness of TCM programs and reduce readmissions, healthcare providers should focus on the following strategies:

  1. Early Discharge Planning: Successful TCM begins before discharge. Providers should assess a patient’s needs for post-discharge care during the hospital stay, creating a plan that includes follow-up visits, medication management, and referrals to other services such as home health care.
  2. Use of Digital Health Platforms: Digital health platforms, such as HealthViewX, can streamline care coordination by connecting various providers, tracking patient progress, and sending automatic reminders for follow-up appointments and medication adherence.
  3. Patient-centered Care: TCM should be tailored to the unique needs of each patient. Personalized care plans that take into account the patient’s medical history, social determinants of health, and family support can improve outcomes and prevent readmissions.
  4. Focus on High-Risk Patients: Patients with chronic conditions, recent surgeries, or social risk factors are more likely to be readmitted. Identifying and prioritizing these patients for TCM services can yield the greatest impact in reducing readmissions.
  5. Data-driven Approaches: Providers can use data analytics to identify patterns in readmissions, enabling them to refine their TCM programs and address common issues that lead to hospital readmissions.

Conclusion

Transitional Care Management is a proven approach to improving patient outcomes and reducing hospital readmissions. TCM programs can significantly lower the risk of preventable readmissions by providing timely follow-up care, coordinating between healthcare providers, and ensuring patients and caregivers are well-informed. As the healthcare industry continues to focus on value-based care, TCM will remain essential in reducing costs, improving patient satisfaction, and enhancing the quality of care.

To fully realize the benefits of TCM, healthcare organizations must embrace innovative solutions, such as digital health platforms, to streamline care coordination and ensure that all patients receive the support they need during the critical post-discharge period.

Sources:

  • Centers for Medicare & Medicaid Services (CMS)
  • Journal of General Internal Medicine
  • Health Affairs

All That You Need To Know About Patient Readmission Rates

What is Patient Readmission?

Patient readmission happens when a discharged patient is again admitted to the hospital within a specified period. CMS used different time frames for research purposes, the most common being 30-days, 90-days and 1-year readmission. They define patient readmission as “An admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital”. It uses an “all-cause” definition, meaning that the cause of the readmission need not be related to the cause of the initial hospitalization. The CMS set the time frame to 30 days because readmission during this time is a result of the care given at the hospital and how well they coordinated the discharges.

Why does Patient Readmission happen?

Before knowing why readmission happens, there are two terminologies that we must know to understand it better.

Index Hospitalization – The original hospital stay i.e when a patient gets admitted for a treatment in a hospital is “index admission”.

Hospital Readmission Rates – The rate at which a hospital readmitted its patients is a “hospital readmission rate”.  In other terms, it is an outcome or a quality measure of care given by health systems.

Here are the top four reasons for patient readmissions,

  1. Importance of paying heed to the physician – Mr. Hayden got admitted to a hospital for a knee surgery. The physician advised him to take complete rest. He did not listen to the physician and strained himself resulting in severe leg pain. Now Mr.Hayden is then re-admitted to the hospital. In this case, the patient should have paid attention to his physician’s advice.
  2. Recovery Instructions – Dr. Adams is a cardiologist. He performed an open heart surgery on one of his patients. Since Dr. Adams was busy with many other surgeries on the same day he couldn’t give the patient instructions regarding post-surgery clinical exercises. He entrusts a nurse with the job. The nurse forgets to instruct the patient about the prescribed exercises. The patient then gets readmitted to the hospital complaining of chest pain. It is the responsibility of the specialist to give the required instructions to his patient and help them recover quicker.
  3. Communication between the patient and the specialist – Mr. Mark gets admitted to the hospital for ulcer treatment. The patient fails to give his complete health problems to the specialist. The specialist does not probe much and gives the usual treatment. Mark is fine for a week after discharge but is then re-admitted for the same problem. It is important for the patient to share all his problems with the specialist and it is the duty of the specialist to understand the complete health history of the patient.
  4. Continuous care to the patient after discharge – Dr. George is an Orthopedic specialist. His patient is suffering from arthritis. The patient needs continuous monitoring and care. The specialist is mostly not reachable over the phone for doubts. Here arises the need for technology, a software that can help both the patient and the specialist in continuous assessment.

Patient readmission risks

Readmission rates decide the quality of care given by the physicians. The CMS introduced the Patient Protection and Affordable Care Act in 2010 penalizing the health systems having higher than expected readmission rates through the Hospital Readmission Reduction Program. They specifically designed the program for incentivizing hospitals that had higher readmission rates of 20% in 2010. CMS reduced the reimbursements of the hospitals depending on the rate of the breach which was effective in reducing the readmission rates by 2% in 2013.

Ways to Reduce Patient Readmission Rates

A study presented by the Harvard Business Review found that on average, a hospital can reduce its readmission rates by 5% if it simply prioritized communication with patients while also complying with evidence-based standards of care. The following steps are a great initiative in cutting down the readmission rates.

  • Scheduling follow-up appointments – After a patient gets discharged it is essential to get in touch with him to inquire about his well-being. The appointments need not be face-to-face always. The physicians can conduct appointments through audio or video calls or sometimes even through messaging or e-mails. It will help the physician in knowing how well the patient is after the treatment or surgery.
  • Long-term relationships with patients – Patient engagement is the key to reduce patient readmission rates. Rehabilitation programs, good nursing team, home care, wellness programs etc can improve patient engagement and thus reduce readmissions.
  • Technology to play a vital role – A software to monitor the patients continuously can really help in solving the readmission rates problem in a cost-effective way. It also provides many other advantages and reduces manual work.

How can technology help in curbing readmission risks?

Information Technology is everywhere, so why not in healthcare? HealthViewX Care Management Solution helps the providers in monitoring and providing care to patients anywhere. It allows the provider to create a care plan for the patient. The care plan comprises many vitals, activities, treatments etc. The provider can select the appropriate ones and create a care plan. The patient who has a mobile application gets notified about the care plan. He can go about recording data for the vitals or measurements given. Both the patient and the provider can view the data in form of graphs or tables which will help the provider to keep an eye on the patient’s vitals. The following features help the hospitals in monitoring the patients easily and thus reducing the readmission risks.

  1. Electronic Care Plans – Care plans to monitor patient’s vitals, measurements, etc. If required,  it can also be printed and handed over to the patient.
  2. Patient Reported Data – Patients can record data for all attributes in the care plan. Summary graphs and table data helps the provider in monitoring the patient’s vitals. The physicians can print reports at any time in pdf or excel form.
  3. Health Device Integration – HealthViewX Care Management Solution can integrate with any wearable device like Fitbit, Apple watch, etc. Hence the patients need not waste time in logging data in the application if they are already using wearables.
  4. Follow-up Appointments – The solution enables to schedule follow-up appointments and sends reminders to both the patient and the provider. It also has inbuilt audio and video calling features to support such meetings.

HealthViewX Care Management Solution offers a range of advantages and lessens the chances of a patient getting readmitted. To know more about our solution, schedule a demo with our expert team who will guide you through the process. Schedule a demo with us to learn more.