Emerging healthcare payment models underscore the widespread belief that reducing hospital admissions will reduce healthcare costs, and although there is not a one-size-fits-all solution to accomplishing this goal, there are lessons hospitals can look to, according to a CSC report published in July.
“There is no magic bullet,” wrote Jane Metzger, a principal researcher for the Falls Church, Va.-based firm’s Global Institute for Emerging Healthcare Practices. “However, there are promising approaches with some research validation that also have been employed in many hospitals with a track record of reducing readmissions.”
One key to reducing readmission rates is comprehensive, patient-centered discharge planning, according to the report. Components of a comprehensive plan include:
- An assessment of transition risks to judge patients' medical and social abilities to avoid readmission;
- Patient preparation to ensure comprehension of current health condition and personal responsibilities for care;
- A post-discharge plan of care that includes recovery goals and involvement from patients, their family members and their providers; and
- Post-discharge follow-up to ensure continuity of care and to offer support services.
Reducing readmissions will require identifying patients at risk for readmission, carefully orchestrated care management programs and patient-specific transition pathways. While this type of patient tracking, collaboration and patient-centeredness has been historically difficult to achieve, health IT should enable more organized care management through tools such as e-prescribing, master patient indexes and electronic clinical communication.
“Hospitals in health systems with integrated EHRs that cross inpatient and physician practice settings have a head start in creating the health IT needed to provide continuity of information during the transition from discharge,” Metzger wrote. “The collaboration, the process and the health IT infrastructure that will enable safe transitions from hospital care for more patients is similar to what’s needed for care management and continuity of care more globally.”
Read the complete report here.