How to Reduce Readmissions for At-Risk Medicare Patients Using Information Technology

Via AHRQ

Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.

Summary:
Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an Area Agency on Aging in Northeastern Massachusetts) visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Administered in partnership with area hospitals, the 4-week program begins with an in hospital visit to determine the risk of readmission. Patients at medium or high risk for readmission receive an in-home visit within 48 hours of discharge and a weekly phone call for each of the next 3 weeks. During each encounter, the coach uses a tablet-based application that provides suggested questions written in lay language based on the patient’s diagnoses, treatment, and overall risk profile. If the answers indicate a decline in health status, the system sends a real-time alert to a nurse care coordinator, who subsequently uses a different component of the software to help the patient and coach address the issue within 24 hours, including arranging for any needed services. The use of health coaches supported by the tablet-based software significantly reduced readmissions among at-risk Medicare patients, as compared with use of health coaches without the software. This reduction generated substantial cost savings for partner hospitals and the health care system as a whole.

You can see the complete study and findings here.