Information Technology: Delivering the Remedy for Costly Readmissions

The healthcare industry is battling a chronic challenge: “boomeranging.” This is when patients are discharged from the hospital – only to bounce back shortly after to be readmitted. One in five Medicare patients ends up back in the hospital within a month of discharge. Often, the causes are failed handoffs and faulty communications between acute care and long-term and post-acute care (LTPAC) providers.

Because readmissions have a negative impact on providers and patients alike, hospitals today are exploring new avenues for preventing the boomerang effect. A key approach is partnering with LTPAC providers – strengthening communications across care settings and improving patient data sharing through technology innovations.

Considering the costs

Readmissions are expensive, costing Medicare more than $17 billion a year. To lower the cost and improve the quality of life for discharged patients, the federal government has taken action. Since October 2012, hospitals with high readmission rates of Medicare patients have faced steep fines, as much as 3 percent a year. More than half of the nation’s hospitals – or nearly 2,600 facilities – are penalized every year for having more patients than expected return within a month. Beginning in October 2018, LTPAC facilities with higher-than-expected readmission rates will also be penalized.

Besides costing the Medicare program billions of dollars, hospital readmissions can negatively affect patients’ physical, emotional, and psychological health. Gaps in provider communication can increase the likelihood of medical errors and conflicting care plans. A readmission event can lead to increased stress, which can weaken a patient’s immune system and put them at risk of contracting other illnesses while back in hospital care. A return to the hospital can also result in depression, further jeopardizing the recovery.

Continuing care across settings

When patients transition from a hospital to their next treatment setting, the shift needs to be closely monitored as it presents many risks. High-acuity discharged patients will continue to be vulnerable and require closely coordinated care. One strategy is using a liaison to bridge the coordination of care between settings. This position called a “SNFist” or “post-hospitalist,” is a provider who specializes in caring for patients transitioning from a hospital to an LTPAC facility. Stationed onsite, the SNFist can catch problems early before they trigger a return to the hospital. LTPAC providers with a SNFist program have reduced readmission rates by as much as 56 percent.

Connecting and collaborating

For acute-care and LTPAC providers, several technologies have proven their potential to keep patients from being readmitted:

  • The electronic health record (EHR): The ability to electronically transfer patient information directly from the hospital EHR to the LTPAC provider’s EHR system gives all providers a comprehensive view of the patient journey. However, a study found most LTPAC providers are far behind acute-care providers in EHR adoption and health data exchange, with only 19 percent reporting EHR capabilities. To fully leverage the power of healthcare data and provide better care, the LTPAC industry will need to ramp up its investment in adopting EHR platforms.
  • Predictive analytics: Predictive data analytics already have a prominent role in value-based care, particularly for patients with multiple chronic conditions. These tools enable LTPAC providers to identify high-risk patients and proactively intervene to lower the possibility of a readmission. Also, root causes can be identified, which can lead to preventing readmissions in specific populations, such as patients with diabetes or congestive heart failure. This analysis supports a more precise discharge process, targeted patient education, and the improvement of care protocols in all healthcare settings.
  • Point-of-care solutions: Touch-screen technologies are extending clinician reach, providing new efficiencies, and improving information accuracy at the point of care. For example, tablet or smartphone apps consolidate patient documentation and caregiver communication, creating a single patient or resident record. Care teams can collaborate through a single device to collect vital signs and document daily care and activities of daily living. They can also communicate through voice and secure text messaging. Providers who do not have a SNFist program can use remote monitoring and video technologies to track patients after discharge to the next care setting.
  • Workforce technologies: Tools can be used to automate work management and provide better use of labor resources. These small changes can reduce time-consuming manual tasks – giving providers more time to focus on patient monitoring and care.


 Creating partnerships for lasting success

As the healthcare industry evolves from independent delivery silos to fully integrated systems of care, the future will belong to organizations who can foster patient-centered approaches. Information technology will continue to empower hospitals and LTPAC providers to work together in reaching their shared goals: lowering costly readmissions, achieving better health care management, and improving patient outcomes.