5 Strategies for Reducing Hospital Readmissions

Reducing hospital readmissions has been a major goal in healthcare for more than a decade. In 2012, the Affordable Care Act (ACA) introduced the Hospital Readmission Reduction Program (HRRP) to incentivize hospitals to reduce readmissions.

A readmission or rehospitalization occurs when a patient who has been discharged from the hospital is readmitted within a certain timeframe—usually 30 days. This issue is crucial because readmissions are costly to hospitals, patients, and payers, and they can negatively impact patient care outcomes and satisfaction.

Why Is It Important to Reduce Hospital Readmissions?

Readmissions are costly to hospitals, patients, and payers, and reduce patient care outcomes and satisfaction. In addition, an estimated 27% of readmissions could be prevented with proper communication between healthcare providers and patients.

Drawing on health data found in electronic health records (EHRs) and health information exchanges (HIEs) can be a good starting point for understanding what patients are being readmitted and why. With that knowledge, hospitals can implement strategies that are proven to reduce the risk of readmission after a patient is discharged.

Breaking Down the Cost

HRRP value based. It allows Centers for Medicare & Medicaid Services (CMS) to reduce payments to hospitals with higher-than-expected risk-standardized 30-day readmission rates for the following conditions and/or procedures:

Acute myocardial infarction (AMI)

• Heart failure
• Pneumonia
• Chronic obstructive pulmonary disease (COPD)
• Coronary artery bypass graft (CABG) surgery
• Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)

CMS calculates the payment reduction for each hospital based on its performance during a rolling performance period. Payment reductions are then applied to all Medicare fee-for-service base operating diagnosis-related group payments during the fiscal year. The payment reduction is capped at 3%.

5 Strategies to Reduce Hospital Readmissions

As the healthcare landscape shifts towards value-based care, it is essential to implement effective strategies to minimize readmissions. Each of these strategies plays a crucial role in improving patient care and reducing the likelihood of readmissions.

1. Use ADT Data for Optimized Transitions of Care

For transitions of care, using claims or authorization data is not very effective because it takes time for that information to be processed and to reach a patient’s clinical provider. Likewise, expecting patients to call their doctor after being admitted or discharged from the hospital is not reliable. However, admission, discharge, and transfer (ADT) data can offer automated, real-time insight into what is happening with a patient.

Working with an ADT provider, hospitals can set up an ADT system as part of their hospital information system that will provide real-time notifications when a patient has an ADT event. Setting up ADT notifications can help with reducing hospital readmissions by giving care teams the opportunity to provide timely outreach and interventions.

For example, Brevard Health Alliance is a federally qualified health center (FQHC) in Florida that worked with PointClickCare to set up ADT feeds in 2018. After setting up their ADT notifications, Brevard was better able to track their patients and provide support, leading to a reduction in readmission rates.

2. Follow Up with Patients after Discharge

It has been proven that a simple follow-up after hospital discharge can be an effective strategy to help with reducing hospital readmissions. One study tested the value of a follow-up call within 30 days of discharge and found that patients who received a call stayed out of the hospital longer than those who did not.

The city of Camden, New Jersey, implemented the 7-Day Pledge Program to connect patients with an appointment to see their primary care provider (PCP) within seven days of discharge from the hospital and found that patients who saw their PCP in the first week post-discharge had lower rates of readmission.

Drawing on ADT data, clinicians and care teams at hospitals should have a process for follow-up in place as part of the intervention and outreach method to prevent rehospitalization.

3. Identify Risk Factors for Readmission Using EHR data

Hospitals can use real-time data and predictive modeling to identify risk factors for readmission. By looking at population health data from the EHR or HIE, hospitals can evaluate common risk factors for readmission and identify patients who meet these criteria for high risk.

A commonly used model for predicting readmissions is called the HOSPITAL score which comprises seven independent risk factors:

1. Hemoglobin at discharge
2. Discharge from an oncology service
3. Sodium level at discharge
4. Procedure during admission
5. Index type
6. Number of admissions in the past 12 months
7. Length of stay

The HOSPITAL predictive readmissions model can be easily utilized because the data it incorporates is readily available in most EHRs and HIEs and can help hospitals to identify high-risk patients more effectively.

If the hospital utilizes ADT notifications for high-risk patients, they can do outreach when a high-risk patient is admitted, discharged, or transferred to proactively support care coordination.

4. Support Patient Medication Adherence to Prevent Rehospitalization

Medication adherence is an important factor when working to reduce rehospitalization. A study of hospitalizations related to medication found that 33% to 69% of those are attributed to medication nonadherence—meaning a patient stops taking their medication or fails to fill their prescription in the first place.

Supporting patients with medication adherence could reduce the risk of hospital readmissions.

Evidence of medication adherence may appear in a patient’s EHR if the patient previously had a medication-related hospitalization; other available data such as any chronic health conditions and a list of current prescriptions could also be utilized to identify patients who should receive support for medication adherence as part of a post-discharge plan.

In addition, clinical staff should work with patients to learn about their ability to access prescription medications before being discharged to help them overcome any potential barriers to getting and taking their medications.

5. Prioritize Patient Understanding of Discharge Instructions

Another way to prevent readmissions is to ensure that patients can understand and follow discharge instructions. When it comes to patient comprehension, studies have found that most patients are not able to remember the discharge instructions they are given or are unaware that they don’t understand.

This may be especially true for patients who are discharged from the emergency department (ED). A study that evaluated patients’ understanding of care instructions after being discharged from the ED found that 78% had deficient understanding in at least one of the following areas: diagnosis and cause; ED care; post-ED care; and return instructions.

Taking a patient-centered care approach can help to ensure patients adhere to care instructions after being discharged.

Doing things like using easy-to-understand language, going over discharge information verbally, and providing digital and/or printed copies can help ensure patients follow care instructions.

Conversations between patient and provider should be a dialogue in which patients can freely ask questions and share any information or concerns with the provider that can help prompt the patient to disclose things like medications they don’t take regularly, and to receive clarification on anything that may have been misunderstood or unclear.

PointClickCare’s Solution to Support Safe Post-Acute Care Transitions

The costs of hospital readmissions are a major concern in the healthcare industry, affecting both the quality of care and the financial health of hospitals. As value-based reimbursement models continue to replace fee-for-service, developing a comprehensive strategy to reduce readmissions is crucial for protecting your hospital’s bottom line.

There is no single solution to reducing readmissions, but a multi-pronged approach can significantly lower the risk of rehospitalization. Ensuring that all providers in your care network have access to accurate, up-to-date patient health information is a critical component of this strategy.

PointClickCare’s PAC Management solutions are designed to support safe post-acute care transitions, helping to streamline communication and coordination among care providers. By leveraging these tools, you can enhance patient outcomes and reduce the likelihood of readmissions.