Big-picture thinking: Care coordination across the continuum reduces readmissions

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Hospital readmissions are a significant driver of healthcare costs and inefficiencies. Addressing this issue is a challenge, however, because of the fragmented nature of the healthcare ecosystem.

During a recent webinar hosted by Becker's Hospital Review and sponsored by PointClickCare, three healthcare experts discussed how enhanced coordination across the care continuum can reduce readmissions:

  • Amy Boutwell, MD, Developer, STAAR, ASPIRE and MVP Methods and President at Collaborative Healthcare Strategies
  • Enrique Enguidanos, MD, CEO and Founder of Community Based Coordination Solutions
  • Nikki Starrett, MS, Director of Value-based Care at Collective Medical, a PointClickCare company

Four key takeaways:

1. Reducing readmissions is hard work, but many success stories exist. Thousands of teams in the U.S. have used the Agency for Healthcare Research and Quality's ASPIRE Guidebook (Designing and Delivering Whole Person Transitional Care) to reduce hospital readmissions. "Over a five-year period, Maryland went from 47th out of 50 states and D.C. for the worst readmission rates in the country to meeting and beating the national average for Medicare readmission rates," Dr. Boutwell said. "They used data to drive performance and foster cross-continuum collaboration." Other effective strategies include creating a community dialogue and leveraging shared technology platforms to support collaboration. "We need to create community multidisciplinary teams with hospital and outpatient providers, law enforcement, emergency medical services, behavioral health centers and jails," Dr. Enguidanos said. "They must include all the touch points for complex readmissions."

2. Emergency departments offer valuable opportunities to engage directly with patients. When it comes to reducing readmissions, understanding the patient perspective is key. Engaging patients during an ED visit—at the point of care—and peeling back the layers on what drove them to the ED can reveal gaps in social supports and other non-medical barriers to care.

"What I love about the PointClickCare tools is that information is available in the ED and dialogue can occur even before a hospitalist gets engaged," Dr. Enguidanos said. "As organizations begin to understand their communities and the available resources, their readmissions drop as much as 50 percent in the first year."

3. Consider proven methodologies, toolkits, and technology platforms. One proven approach is the Institute for Healthcare Improvement's STAAR initiative (STate Action on Avoidable Rehospitalizations) which focuses on aligning stakeholders across the care continuum to impact readmissions at a regional level. Another is the INTERACT (Interventions to Reduce Acute Care Transfers) methodology. "This set of recognition tools and evidence-based protocols are designed to respond to small changes in clinical status safely and manage them on-site, instead of reflexively sending someone to the emergency room for evaluation of smaller issues," Dr. Boutwell said. "This toolkit has reduced readmissions among post-acute patients by an average of 35 percent."

Technology platforms that support cross-continuum information sharing can also help reduce readmissions from a post-acute setting, where patients have a high risk of readmission, by providing post-acute providers with key context about the patient they are caring for and connecting them with other care team members.

4. Technology solutions should do more than push data; actionable insights are key. The right solutions will transform data into insights for individual patients, so the right provider or care team member has actionable information to make the best decisions for patients. Ms. Starrett explained that the care team needs to “stay engaged with what’s happening during a SNF stay and identify patients who require attention- for example if a patient, has long length of stay, low functional status, or is at high risk of readmission”. Insights at the network level are also key. “To reduce readmissions, you need to understand how the network is performing. If individual facilities are driving readmission rates, you must address those problem areas proactively," Ms. Starrett said.

PointClickCare and Collective Medical are uniquely positioned to support enhanced care coordination through real-time and bi-directional data exchange, as well as workflow integration through our industry-leading Value-based Care solution.

 

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