Avoiding and reducing readmissions keeps your members and the system itself healthier. Reaching this goal can be challenging because so many factors impact it. However, a concerted effort between providers and plans using best practices and proven strategies can significantly lower readmissions.
Readmission is a complex topic with many variables, such as type of disease, treatment complexity and social determinants of health (SDOH). Taking advantage of tools, technology, data and innovations and implementing a simple, scalable plan can help you achieve reduced readmissions.
Here, we’ll review the state of readmissions and provide tips and recommendations for mitigating the risks.
The state of readmissions
Readmissions can have dire consequences for providers. Financial penalties can arise from high readmission rates, as denoted by the Hospital Readmissions Reductions Program (HRRP). In the 10 years since its origination, nine out of 10 acute-care hospitals have received a penalty. Thus, all stakeholders have an incentive to ensure these rates decline.
What does the healthcare ecosystem know about the cause of readmissions? A study published by JAMA Internal Medicine discovered that 27 percent of readmissions were considered potentially preventable. The reasons for these readmissions included medication nonadherence, care coordination failures, lack of discharge or advance care planning and more.
The researchers submitted that improved communication between teams and patients, increased attention to discharge readiness, enhanced monitoring and better self-management could minimize the readmission risk.
Even with programs and initiatives to support prevention, readmission is still a prevalent issue. Health plans need to be part of the solution and develop better ways to support providers. Doing so reduces healthcare costs, ensures better outcomes for members and gives hospitals the capacity to care for more individuals.
So what are the best ways to reduce readmissions?
1. Focus on medication adherence with medication reconciliation
When your members don’t follow their prescription orders, it can lead to readmission. The link between nonadherence and readmissions comes from research from Duke Health. The conclusion was that nonadherence increases costs and readmissions.
Another study found that 11 percent of discharged patients had an adverse drug event, of which 27 percent were avoidable.
The best way to avoid readmissions due to prescriptions is with medication reconciliation. This is when providers compare medication orders to medications taken. You can also use intervention programs post-discharge that deliver communications about taking medicine daily, when refills are due and other helpful reminders.
2. Educate patients and involve them in care plans
Miscommunications or misunderstandings about post-discharge care are common causes of readmission. Unfortunately, the healthcare setting is a busy place. Sometimes, there’s no plan for keeping your members healthy at home.
One way to combat this is developing inpatient education about diseases, treatment plans, symptoms, medications, nutrition and more. Studies show that most patients forget discharge instructions. It happens even more frequently for emergency department (ED) discharges.
No matter the length of stay or reason, providing care plans early and often can combat this forgetfulness. If engagement occurs from the start, they have a better chance of understanding and recalling discharge orders. Documenting care plans and sending them with the patient supports continued adherence.
3. Identify key risk areas with data
Healthcare data regarding your members' history, diseases, treatments, vitals, living environment and more can help you predict the chance of readmission. Many healthcare providers use the HOSPITAL score, which comprises seven risk factors and is already a core feature of an electronic health record (EHR) system.
Beyond the HOSPITAL components, SDOH are critical. They are involved in the HOSPITAL score to a degree. One study revealed that individual- and community-level SDOH augmented the score and improved predictions about readmission.
Plans already have programs to cover the SDOH factor. Still, yours may be lacking a critical component—the loneliness factor.
4. Develop a program to address loneliness as a factor in readmissions
Loneliness is a complex condition. It’s more than just being alone. Rather, it’s a complex condition. Loneliness, in small doses, is like hunger or thirst, which are healthy signals from the body that we’re missing something. When loneliness becomes chronic, it becomes something that needs treatment and intervention due to its impact on mental and physical health. Plans need to also realize that those who are lonely use health care differently.
For example, data revealed that 80 people went to Dallas emergency rooms 5,139 times in a year. Why? Most people would correlate to poverty, SDOH, or lack of access to primary care. Those did contribute o to this number, but the primary factor was loneliness. They lacked relationships and social structures, so their interpretation of how to seek medical care was just to go to the ER.
That means, health plans have to treat lonely members differently than others. But loneliness is a complex condition.
It may seem there isn’t a way to address such a complicated area. It’s also not something at the forefront of plan or provider mindsets when considering total health.
How do you treat loneliness and ensure it doesn’t factor into readmission risk?
It’s a two-part process involving both technology and a human touch. To create connections and improve outcomes, we designed programs centered on reliable, consistent, resource support, compassion, and companionship for Medicaid and Medicare members.
The reason behind using technology with a human touch is that the former is scalable, and the latter is personal. This tech offers a member-centered approach, allowing members to document symptoms and feelings through quick assessments. From this data, we develop the right interactions to deliver empathetic care.
The next part is the connection, which includes interactions with our chatbot and compassionate teams who aren’t limited by how long they can speak with members. They can call as often as they’d like! This personal connection builds trust, reduces depression, guides members to resources and helps them thrive.
To learn more about the science of loneliness and how developing a program to solve it can reduce readmissions, read our white paper.
