The transition from hospital to home is a vulnerable time for any patient. It is especially difficult for the frail, the elderly, and those with multiple chronic conditions. The care patients receive after a hospital stay is often siloed and fragmented. Care plans can be conflicting; services, duplicated; and medications, unreconciled. The result? Higher-cost, lower-quality care – and sicker patients who land back in the hospital in less than a month.

“The key to successful transitions is continuous care coordination across all settings, along with relentless patient follow-up,” says Robin Hill, vice president of clinical solutions at Vivify Health, a fast-growing international digital health company. “These synergies in care lead to engaged patients and improved health outcomes.”

Preventing hospital readmissions

Statistics tell the story. One in five patients discharged from hospital to home experiences an adverse event within three weeks, while one in five Medicare patients is readmitted within 30 days of discharge – at a cost of more than $26 billion each year. According to the Medicare Payment Advisory Commission, as many as 76 percent of readmissions are preventable.

Intent on reducing unnecessary readmissions, the Centers for Medicare & Medicaid Services introduced penalties for providers with relatively higher rates of Medicare readmissions. Much of the focus is on improving the discharge planning process. To avoid financial consequences and deliver continuous quality care, hospitals are seeking the best approach to staying connected with patients after they return home.

Creating a model for transitions

A seminal model in addressing the readmission challenge is the Care Transitions Intervention program. Created by geriatrician Eric Coleman, MD, the four-week program is designed to foster patient engagement and facilitate a smooth transition from hospital to home or other care setting. The program includes a specially trained care transition coach who helps discharged patients develop self-management skills. A home visit is scheduled within 72 hours of discharge, followed by weekly phone calls to check on patient progress.

“Almost all hospitals today have a care transition program, using a modified Coleman model or creating their own,” Hill says. “The goal is to touch base with patients, making sure they’ve scheduled follow-up appointments with their primary care physician, they’ve had their prescriptions filled, and any ancillary services – such as physical therapy and food assistance – are taken care of.”

These transitional care programs can help reduce re-hospitalization, alleviate patient anxiety, and improve overall safety and quality of care, Hill notes. Yet because they are resource intensive, they are often challenging to implement. Also, care transition coaches may have a long way to travel to patients’ homes, reducing the number of patients to whom they can deliver services.

Extending the model through remote care monitoring

A viable solution for addressing the resource issue in care transition programs is remote care management (RCM) technologies. According to Hill, an effective RCM program can promote successful transitions by:

  • Providing a streamlined way to communicate the post-acute care plan. Hospitals can convey clear care instructions and needed follow-up activities, while patients and primary caregivers have ready access to the plan. Algorithms can be customized to meet any type of discharge scenario.
  • Enabling clinician intervention. Patients record their biometric readings and answer questions about their care plan. Any readings or answers outside of the patient’s wellness parameters will alert the care transition team, who will review the data, contact the patient, provide further guidance, and escalate medical interventions, if needed.
  • Allocating clinician time. With RCM, care transitions can be readily scaled. The need for an initial in-home visit is greatly reduced, while patients are monitored more consistently. The care transition team can gain efficiencies in workflow while spending more time with each patient through interactive videoconferencing.
  • Engaging and educating patients and families. Patients respond to health coaching and health measurements through a simple touch-screen interface. Scheduled follow-up calls and clinical assessments ensure compliance with care pathways and involve patients and their families in healthcare decisions. Educational content ensures patients understand their condition and protocols for recovery. Family members who are geographically distant can connect directly with the patient for status check-ins.

“The return on investment for using RCM technologies in care transitions is compelling,” Hill says. For example, in a one-year pilot project to reduce readmission for its high-risk patients, a Texas-based health system realized a 90 percent reduction in overall cost of care, a 65 percent reduction in hospital readmission, and a $2.44 return for every dollar invested by the fifth month of the program. Patient adoption and overall patient satisfaction ranked at 95 percent.

Capturing the opportunity for collaboration

Monitoring discharged patients through RCM technologies is a prime opportunity for provider and payer collaboration, Hill notes. As is true of providers, payers have a financial incentive to keep patients in their homes. The healthier the patient, the lower the cost. Working together, providers and payers can use RCM to better manage the health of their patients and members – and invite them to be true partners in their own recovery.”

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