Lowering Hospital Readmissions: Leveraging the Power of Information Technology    

July 16, 2018

By Angela Norris

It’s been called “boomeranging”—patients being discharged from the hospital and bouncing right back for readmission. Almost 20 percent of discharged Medicare patients are readmitted within 30 days. Often the cause of readmission is failed handoffs and communication problems between acute care and long-term and post-acute care (LTPAC) providers.

To thrive in today’s era of value-based care, hospitals are considering new approaches to avoiding costly readmissions, including partnering with LTPAC providers in quality initiatives and collaborative problem solving. At the heart of these strategies is sharing information across settings to improve patient care.

Addressing the high cost of readmission

Readmission comes at a high price—$17 billion annually—but the cost goes beyond dollars. Patients often suffer physically and emotionally. The stress of readmission can weaken the immune system, leaving the patient at risk of contracting other illnesses or infections while back in hospital care. Because of gaps in provider communication, instructions on medication, testing, and care plans are often conflicting, increasing the danger of medical error. Returning to the hospital after being discharged can also result in depression, triggering a downward spiral

Navigating a value-based world

Over the past several years, the federal government and the healthcare industry have maintained a laser focus on preventing avoidable readmissions. The goal is to lower healthcare costs and improve quality of life for discharged patients, many of whom have multiple chronic conditions. In October 2012, the government began fining hospitals for high readmission rates of Medicare patients. Beginning October 2018, LTPAC facilities with higher-than-expected readmission rates will also be penalized. In a delivery system intent on rewarding efficiency and value, hospitals will be looking to build networks with LTPAC providers who consistently demonstrate reduced readmissions and high-quality patient outcomes.

Ensuring care continuity

The move from the hospital to the next healing environment is rife with challenges. High-acuity discharged patients are vulnerable and require closely coordinated, continuously monitored care. One strategy for lowering readmissions is using a liaison to bridge care between settings. This position, called a “SNFist,” or “post-hospitalist,” is a practitioner who specializes in caring for patients that have been transitioned from the hospital to a LTPAC facility. Stationed onsite, the SNFist is likely to catch problems early before they require a return to the hospital. LTPAC providers with a SNFist program have been found to reduce readmission rates by as much as 56 percent.

Exchanging information  

Across the continuum, seamless information exchange continues to be the catalyst for delivering unified care. For LTPAC providers, several technologies have the proven potential to keep patients out of the hospital:

  • The electronic health record (EHR). The ability to electronically transfer patient information directly from the hospital EHR to the LTPAC provider’s EHR system enables all providers to have a holistic view of the patient journey. A seminal study finds, however, that most LTPAC providers lag far behind acute-care providers in EHR adoption and health data exchange, with only 19 percent reporting EHR capabilities. To ensure up-to-date patient information and provide better care, the LTPAC industry will need to scale up its investment in EHR adoption.
  • Predictive analytics. Predictive data analytics have a prominent role in value-based care, particularly for patients with multiple chronic conditions. With analytics, LTPAC providers can identify those at high risk and proactively intervene to lower the likelihood of readmission. Root causes can be identified that lead to the readmission of specific populations – such as patients with diabetes or congestive heart failure – to provide more precise discharge instructions, target patient education, and improve care protocols in all care settings.
  • Point-of-care solutions. Touch-screen technologies are extending clinician reach, creating efficiencies, and improving accuracy at the point of care. Tablet or smartphone apps, for example, consolidate patient documentation and caregiver communication, yielding a single patient/resident record. Using one device, care teams collaborate in collecting vital signs, documenting daily care and activities of daily living, and communicating through voice and secure text messaging.
  • For those without a SNFist program, remote monitoring and video visits between patients and providers can enable hospitals to track patients after discharge in the LTPAC setting. Clinicians can monitor and assess patients through remote bedside support, minimizing return trips to the hospital.
  • Workforce technologies. Tools that automate work management provide better use of labor resources, reduce time-consuming manual tasks, and empower caregivers to focus more fully on the patient relationship.

Partnering for success

As our healthcare system continues to transform from delivery silos to fully integrated systems of care, the future belongs to organizations that build patient-centered partnerships. Information technology empowers hospitals and LTPAC providers to work together in reaching shared goals: lowering readmissions, achieving better care management, and indelibly improving patient outcomes.

CREDIT—Angela Norris is Senior Vice President of Business Development, StoneGate Senior Living. Norris will expand on the use of information technology to lower hospital readmissions as a speaker on the Technology executive discussion panel at the fifth HealthTAC produced by Senior Living News—HealthTAC West, Monarch Beach Resort, Dana Point, CA, August 19-21. StoneGate is the industry’s 31st largest senior care and rehabilitation network.


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