Hospital readmissions drive costs and negatively impact health outcomes. However, many are preventable with the right plans, initiatives and strategies. Although you are keenly aware of hospital readmission rates and reasons, what are you not considering? If you want to explore how to decrease hospital readmission rates, you need to consider a new approach. It should incorporate what you know about readmission risk factors and what you don’t. Namely, you must consider the role loneliness plays in hospital readmissions.
Identify root causes and high-risk members
Technology, tools and new perspectives are available to support you and your members so that their chance of readmission declines. This starts with identifying root causes by analyzing your member data, then determining who is most at risk for readmission. A higher risk of readmission often involves:
- Comorbidities and chronic conditions, especially for members in the “target admissions” segment.
- Poor health history and previous readmissions.
- Social determinants of health (SDOH) that affect recovery, such as food insecurity, lack of transportation and lack of access to post-op treatment and medications.
- Low level of caregiver support at home.
After identifying these members, you can strategize on how to intervene before they leave the hospital. There are three key components: ensuring medication adherence, utilizing a transition of care model and addressing chronic loneliness.
Ensure medication adherence and reconciliation
Your members won’t make a timely recovery without adhering to their medication. Medication non-adherence is a leading cause of readmissions and often results from a lack of access or understanding.
The other issue relating to prescriptions is medication reconciliation. This is the process of comparing a patient’s medication orders to what they are actually taking. Reconciling at discharge acts to prevent omissions, duplications, dosage errors, or drug interactions.
Failure to reconcile can cause adverse drug events (ADEs). A study of ADEs found that 11 percent of discharged patients suffered such an event, with 27 percent of those being preventable.
To ensure your members have access to the correct prescriptions, you can:
- Give them information on how to receive medications at home.
- Reconcile orders versus medicines taken.
- Send medication information to members via multiple channels (e.g., mail, email, member portals).
- Check-in with patients through phone calls to ask about their medication regimen.
Leverage a transition-of-care model
Hospitals typically use a transition-of-care model when discharging patients. Still, Medicaid plans can also get involved with this care delivery. Coordination of all parties — plans, members, caregivers and health team members — leads to better results across the board. The key is to engage the member (and their caregiver, if applicable) so they are more likely to adhere to the plan. That often includes:
- Designing a continuity of care plan, which means scheduling follow-ups with physicians and for other treatments after discharge.
- Encouraging medication self-management, including education on what prescriptions to take and when.
- Providing education about recovery or tools and resources to help members better understand a new diagnosis.
Use interventions for the silent factor of loneliness
Loneliness is not just a feeling. It’s a devastating, pervasive health care issue with human costs, impacting mental and physical health.
Loneliness as a condition that impacts health is a new focus in health care and is becoming a more prevalent topic for plans and clinicians. The science of loneliness and its impact on health outcomes is staggering, proving it is a powerful agent that impedes healing.
People who are lonely use health care differently than those who are not. They lack relationships and support, and often end up in the hospital. That was the conclusion of Dr. Jeffery Metzger, chief of emergency services at Parkland Health and Hospital System, after identifying 80 patients who had collectively been in his emergency room 5,139 times in one year. This story isn’t unique, as those with chronic loneliness are often high-utilizers of these systems because they lack support.
The Pyx Health platform is an innovative merging of technology and human compassion that builds connections with vulnerable plan members. These connections occur outside the traditional care setting, and they are not transactional. Instead, the solution is all about establishing genuine relationships with your members so that they have the support needed to engage more fully in their health and make better decisions.
The solution finds members with a propensity for loneliness and assesses their emotional state. Then it provides the opportunity for members to connect through scalable technology and compassionate humans they can speak with whenever they need. This holistic and evidence-based approach has proven to be successful in reducing readmission rates.
Visit our Resource Center to learn more about addressing loneliness through technology to drive down utilization costs and decrease readmissions.
