Using IT to reduce readmissions for at-risk Medicare patients

Health coaches who used tablet-based software and worked with at-risk Medicare patients were more effective in reducing readmission rates than health coaches who did not use the software when working with the same demographic, according to an Innovations Exchange report by the Agency for Healthcare Research and Quality.

Trained health coaches at Elder Services of Merrimack Valley in Lawrence, Mass., visited recently discharged Medicare patients in their homes to assess and identify any health status changes that may increase their risk of readmission. Some health coaches were equipped with tablet-based software that provides suggested questions to ask the patient to help assess their health status. If patients' answers suggest a decline in health status, the system alerts a nurse care coordinator in real-time who can then help the health coach and the patient address the issue within 24 hours.

The trial project lasted six months. In that time, patients whose health coaches used the tablet-based software had a 39.6 percent reduction in 30-day readmissions, according to the report. The reduction in readmissions also saved an average of $109 per patient per month, totaling net savings of approximately $370,000 over the six-month period.

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