Three Communication Interventions That Reduce Readmissions
Article originally appeared here
New Jersey-based Kennedy Health (now Jefferson Health) recently made a remarkable discovery: Within one six-month period, just 21 patients accounted for 903 visits to its ED. Many of them, of course, were ultimately readmitted to the hospital.
“We were having difficulty getting a handle on [the super-utilizer] population of patients, because often the accepting floor team didn’t know about the patient until the emergency room had already evaluated them and made the decision to bring them in the hospital,” says Dr. Maryann Lauletta, Vice President of Medical Operations.
Readmissions are clearly a challenge for most hospitals. Nearly 2,600 hospitals will face CMS reduced-reimbursement penalties in 2018 as a result of their readmission rates—that’s about 80 percent of the hospitals evaluated by CMS.
Health systems are targeting everything from infection-reduction protocols to population health strategies in attempts to rein in their readmissions. However, there are several simpler ways that a unified clinical communication platform can move the needle on readmission rates. The cutting-edge tools you’ll find on an enterprise communication system reduce readmissions by improving care consistency, helping patients adhere to essential follow-up care, and ensuring that critical information doesn’t get lost after discharge. Here are a few examples.
Read Kennedy Health’s full story here.
Kennedy Health enabled a readmission alert system on the TigerConnect communication platform to notify key providers and care managers when a returning patient presented at the ED. Care team members familiar with the patient were able to meet him in the ED to see if his care could be managed without a readmission to the hospital. Often, readmissions could be averted with a simple medication adjustment or a referral for outpatient care.
Automated alerts can be set up in numerous scenarios, including:
- Admit, Discharge and Transfer (ADT) alerts can notify primary care physicians of their patients’ hospital activity. A PCP who receives an automated discharge alert can review discharge orders and prescribed medications to ensure success with post-care regimens.
- Task lists can intelligently route tasks to the appropriate care provider or allied staff member to ensure medical equipment, medication reconciliation, or transportation home is arranged.
- Discharge alerts routed to a care manager or nurse navigator can initiate a workflow to assist the patient with scheduling essential follow-up appointments or arranging vital home care services.
Team Collaboration Functionality
With as many as 26 percent of patients reporting that they receive conflicting information from their various doctors, care team communication takes on new significance in the context of readmissions. Patients cannot adhere to their post-discharge instructions when it’s not clear what they are.
Team collaboration tools allow clinicians to:
- Build groups around patients, which enables the inclusion not only of physicians and nurses but also physical therapists, care managers, pharmacists and more
- Message anyone, regardless of hospital affiliation—an essential feature to keep out-of-network primary care physicians informed of patient treatment plans
- Integrate lab and PACS, so clinicians can access critical results on their smartphones and share them securely with colleagues in and outside of the hospital system
- A unified clinical communication platform connects care teams so that everyone involved in a patient’s care is updated and current on all treatments and recommendations. This is the most effective and efficient way to speak to a patient with one voice and keep them on track for recovery.
It’s not always clear which physician is responsible for post-discharge follow up. Is it the primary care physician, who may or may not have been notified that his patient was hospitalized? Or, is it the cardiologist the patient was referred to by the hospitalist who discharged him? The physicians don’t always know, either, according to this study published in the Milbank Quarterly.
Handoff coordination tools connect providers for direct collaboration, so it’s extremely clear who is responsible for overseeing the patient’s next steps. Images and test results can be securely forwarded from one provider to the next. Primary care physicians can access role-based automated scheduling to locate and coordinate discharge instructions with the on-call hospitalist. And, nurse navigators can see entire care plans to ensure that the after-care assistance they provide for the patients is correct and current.
As for Kennedy Health, within the first three months of implementing a clinical communication program, they saw an 8.8 percent reduction in readmission rates for COPD and a 22.2 percent reduction for CHF patients. ED visits among those 21 super-utilizers also dropped 73 percent.
The results represented a win for everyone, says Mike Neuman, Kennedy Health’s Assistant Vice President of Business Intelligence and Analytics.
“We’re keeping them out of the hospital, reducing our cost, and providing a much better experience for the patient,” he says.
Reducing readmissions is one way to improve profitability in your health system. Download the Revenue Rescue eBook to learn more.