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.

How can hospitals decrease readmission for Medicare patients?

One of the goals of the new Affordable Care Act is for hospitals to decrease the number of patients that are readmitted into the hospital after they've been discharged.  Studies show that currently, one out of five Medicare patients are readmitted in 30 days while 35% are readmitted within 90 days.  This costs the government $17 billion.  So as incentive to change this the Affordable Care Act is tying reimbursement to how many patients are re-admitted into the hospital.  One of the key reasons for this is patients aren't aware of how to properly care for themselves after they leave the hospital, often due to miscommunication in the discharge process.

In this article from the Washington Post, they share that researchers from Northeastern University have developed an avatar that patients can watch from their hospital beds on TV that go over their care instructions after they're discharged from the hospital.  This is called "Project Red", and has shown that readmission for patients have dropped by 30% in use during clinical trials.

At the 9th Annual Medicare Congress, Charles Mackay, CPHQ, Health Insurance Specialist, Centers for Medicare & Medicaid Services will be keynoting a speech entitled "Health Rebooted: How Taking Technology All the Way will Solve Both the Cost and Quality Problems" which will look at technologies like this and others that can improve the care of Medicare patients and efficiency of hospitals.  For more information on this presentation and the rest of the program, download the brochure here.  Don't forget, as a reader of this blog, mention code XP1707BLOG to receive a discount of 25% when you register to join us this February in Orlando!

Do you believe a process like this can help both hospitals and patients?