Readmission rates are a critical metric for hospitals, affecting quality ratings and reimbursement. Neil Smiley, CEO of Loopback Analytics, discusses the growing relationship between hospitals and community-based care transition programs that seek to reduce the number of unnecessary 30-day hospital readmissions.
Note: Interview has been lightly edited for length and clarity.
Q: What strategies do hospitals and health systems commonly use to reduce patient readmissions?
Neil Smiley: When readmissions first became a focus, hospitals started by improving the discharge process within their own walls through quality improvement programs like Project RED (Re-Engineered Discharge). While these programs helped, it quickly became evident that the biggest contributors to readmissions were outside the hospital. Hospitals then extended their reach through post-discharge follow-up calls with particular emphases on medication adherence and timely follow-up with a patient's primary care physician. Medication adherence has consistently been the number one driver of readmissions, and engaging with patients after discharge through phone-based pharmacist consults has proven to be very effective in reducing readmissions. However, phone-based follow-up is not sufficient in reaching many high-risk patients. Hospitals have also assigned community-based health coaches and case managers to work with patients as they transition from hospital to home to address both clinical and non-clinical risk factors.
At this point, most hospitals are applying some, if not all, of these interventions to varying degrees. The new emerging area of focus is improving coordination with facility-based and home-based post-acute care providers. Hospitals are working to get better visibility of what happens to patients after discharge and are demanding more reliable outcome data from their post-acute care partners. In some cases, hospitals are narrowing their post-acute care referral networks to only those downstream providers that have demonstrated good outcomes and are committed to data sharing and high-quality care. While readmission penalties provided the initial impetus for action, increasingly hospitals are bearing more financial risk through relationships with ACOs, managed care contracts and bundled payments.
Q: How can community-based organizations help reduce readmission rates?
NS: Community-based organizations are ideally positioned to provide post-discharge follow-up programs that extend into a patient's home. Many of the factors contributing to readmission begin with non-clinical issues that subsequently manifest as a clinical condition. Community-based organizations can help with patients before their condition deteriorates through in-home services to address health literacy, transportation, nutrition, financial assistance, fall risk prevention and other needs. Community-based organizations are also adaptive to the language and culture variations of patients in their community and can be a gateway to a wide array of services to help ensure a successful transition from the hospital.
Q: How can hospitals and health systems partner with community-based organizations on initiatives to reduce readmissions?
NS: The collaboration between hospitals and community-based organizations is still fairly new. Both are still learning what the other needs to be successful. Hospitals want assurance that the services provided by community-based organizations are producing cost-effective readmission reductions. Community-based organizations need a steady referral stream of qualified patients to manage efficient operations and keep per-patient costs low. Systems are needed to proactively identify high-risk patients prior to discharge who would most benefit from community services with accurate reporting to confirm the investment in community-based services is resulting in cost-effective reductions in readmissions.
Q: What do you think will be a few of the key strategies to reduce readmissions to emerge over the next few years?
NS: To make continued gains in readmission reduction, both hospitals and community-based organizations will need to get better at leveraging data to stratify patient risk and match specific risk characteristics with the appropriate intervention strategies. It is not cost effective to provide the same interventions to all patients. Community-based organizations will also need to come together into larger networks to provide hospitals and health systems with geographic coverage. The portfolio of intervention solutions will also need to expand to address unmet needs that continue to contribute to readmissions. Technology will play a big role, including data sharing across providers and telemonitoring to ensure that problems are detected early and acted upon appropriately.
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