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10 Proven Methods: How to Reduce Hospital Readmissions

10 Proven Methods: How to Reduce Hospital Readmissions

Experiencing hospital readmission within 30 days is often considered a failure in the eyes of providers and their patients, and certainly to the Centers for Medicare and Medicaid Services (CMS), who penalizes these occurrences. The costs are high—physically, mentally, and financially. These are the key reasons why you need to know how to reduce hospital readmissions. 

But there’s another reason why it’s important to reduce hospital readmissions, and it’s a big one.

High readmissions indicate a hospital’s or team’s quality of care, which is utilized for assessments by authorities. For these reasons, lowering readmissions has been at the forefront of healthcare research. This research shows there are some strategies and tools that hospitals should employ if they will reduce hospital readmissions successfully.

1. Understand Federal Policy

Under the Hospital Readmission Reduction Program (HRRP), established in 2012 by the Affordable Care Act (ACA), the Centers for Medicare & Medicaid Services (CMS) incentivize hospitals with payment adjustments “to improve communication and care coordination efforts to better engage patients and caregivers in post-discharge planning.” 

The purpose of the incentives is to “add quality measurement, transparency, and improvement to value-based payment in the inpatient care setting.” It gives an “opportunity to improve the quality of care and save taxpayer dollars by incentivizing providers to reduce excess readmissions.”  

The maximum penalty for excessive rehospitalization in fiscal 2021 is a 3% cut in payment for each Medicare patient, with the average penalty across hospitals totaling 0.69%.

Questions to Ask:

  • How does your hospital rank nationally for readmission averages? 
  • Are you reliant on “entrenched silos of care, where acute care hospitals [are] largely incentivized to get patients only well enough to leave the hospital” instead of providing supportive, transitional care?

2. Identify the Patients Who Are Most at Risk for Readmission

Healthcare providers must rely on two types of data to assess each patient’s risk for hospital readmission within 30 days. 

ML (Machine Learning) ADT (Admission, Discharge, and Transfer) data: This includes real-time data generated by EHRs to instantly update and notify physicians and nurses on patient status, thereby capturing and summarizing important contextual information.

Questions to Ask:

  • Is the data we gather sufficient for assessing actual risk for each patient?
  • Are we using the data to its fullest ability?

3. Prevent Healthcare-Acquired Infections

A study published in NCBI notes that “patients with a positive clinical culture obtained more than 48 hours after hospital admission had an increased hazard of readmission.” Also, “the incidence of 30-day readmission among patients with a positive clinical culture result was 25%, compared with 15% for patients with a negative result or no clinical culture.” Lastly, “healthcare-associated infections are also associated with considerable morbidity and mortality among infected patients.” 

Questions to Ask:

  • Is patient risk properly assessed and accounted for before, during, and after admission? 
  • Are there better infection control policies and procedures that can be put into place at your hospital? 

4. Use a Transition of Care Model

Dr. Eric Coleman, Principal Investigator of Care Transitions at the University of Colorado, published his Care Transitions Model to encourage hospitals to use The Four Pillars of Care Transitions to help patients and their caregivers self-manage their home care.
Another option is the Transitional Care Model published in OJIN, which was developed so nurses can help reduce hospital admissions.
Questions to Ask:
  • How can your hospital focus on improving care, enhancing patient outcomes, and reducing costs among the “vulnerable, chronically ill, older adults identified in health systems and community-based settings”? 
  • Is care prepared, coordinated, and delivered in collaboration with patients, their caregivers, and other health team members?

5. Confirm a Dependable Caregiver

A study performed by the University of Pittsburgh Health Policy Institute discovered “discharge planning interventions with caregiver integration were associated with 25% fewer readmissions at 90 days.” 
Questions to Ask:
  • Should home healthcare be prescribed? 
  • Does the patient have reliable assistance with transportation and hygiene needs?
  • Does the caregiver have all the needed information? 
  • Do you need to contact social workers to provide resources for these needs?

6. Support Medication Adherence

To quote the study Medication Adherence: Truth and Consequences, “Patients are nonadherent to their medicine 50% of the time. Improving [this] may have a greater influence on the health of our population than in the discovery of any new therapy.”
Questions to Ask:
Does the patient have a clear list, an understanding of, and access to all their medications, including those they were prescribed before hospitalization?

7. Discuss Warning Signs

Patients with severe mental illness (SIM) experience extremely high readmission rates. Of the patients discharged from psychiatric wards, “23.8% were re-admitted between 8 and 30 days. One percent of the patients experienced many admissions and readmissions,” accounting for “22% of the cumulative treatment costs.”
Since recent evidence shows these patients have similar decision-making capacity as non-psychiatric patients, “shared decision making improves self-efficacy and autonomy, and improves treatment outcome.” 
Questions to Ask:
  • Does the patient know the early warning signs of a problem and how to address them? 
  • Do SIM patients have a say in their preferred relapse prevention and treatment plan?

8. Establish Necessary Follow-Up Care

Clinicians and care teams see the value in following up with their patients after being discharged from the hospital. JAMA found when follow-up is completed within seven days, readmission rates dropped from 17.5% to 12.7%.
The study suggests that other successful follow-up care interventions include “patient incentives to overcome barriers to keeping an appointment” and “reimbursements to practices for prioritizing patients recently discharged from the hospital.” 
Questions to Ask:
  • Is transportation or time an issue for a patient to make it to a follow-up appointment? 
  • Are other options made available to them (i.e., an in-home or telehealth visit)?

9. Prioritize Patient Understanding of Discharge Instructions

The patients who are empowered to help their recovery process have lower rates of readmission than those who feel they have no control over it. During discharge, part of a provider’s role is to empower their patients to play an active, effective role in maintaining their own health (when advisable). 
Hospitals should provide patients with detailed written and pictograph instructions of active issues, services needed, warning signs, and emergency contact information. Patients also have the right to have this information interpreted for them in their own language. 
Questions to Ask:
  • Are the patient's condition, treatment, care plan, anticipated problems, etc., up to date?
  • Can provider and patient have an uninterrupted two-way conversation?
  • Is there enough time afforded for asking and answering questions?
  • Do you use the Teach-Back method (which can potentially reduce readmission rates by 45%)?

10. Use Specialized Tools to Reduce Hospital Readmissions

The resources and coordination needed to succeed at reducing readmissions can be very complex. Fortunately, some solutions simplify this process and deliver outstanding results. 
With the advent of hospitals using specialized tools to reduce hospital readmissions, early high-risk patient identification is becoming increasingly possible. These tools do this through prediction models that are implemented upon patient admission and discharge. Engaging patients throughout their discharge journey through 30 days and beyond is another key factor in lowering risk.
Questions to Ask: 
Can you leverage consumer science and psychographics to motivate and activate patient behaviors?
How can you simplify each provider and patient interaction? 
Learn More About PatientBond
PatientBond’s easy-to-use platform enhances the likelihood of recovery by utilizing all the above strategies to reduce hospital readmissions and keep your CMS incentives in check.
Calculate your hospital readmission reduction ROI and request a PatientBond demo to help deaden the negative financial impact facing your hospital.

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