Readmissions was so yesterday

Yesterday. No, not a Beatles song.

With two-thirds of the nation's hospitals at risk of a Medicare pay cut under the Hospital Readmissions Reduction Program, the time to improve post-discharge planning and care coordination was yesterday.

But what can be done today?

According to experts in Health Affairs, 2,225 hospitals will incur $227 million in penalties for fiscal year 2014. But according to a study in JAMA, the vast majority of readmissions are unrelated to the previous hospital stay.

The key to curbing readmissions is a primary care problem rather than a hospital program. Primary care plays an integral role in helping patients fully recover, and coordination between inpatient and outpatient teams is key to ensuring success. It begins with managing readmissions from a population perspective, rather than from a facility perspective.

At the 5th Annual ACO Summit held in Austin, Texas, recently, panelists were asked about what that population perspective might look like. Here are five points from that discussion.

1) We need more and better data.

What does more and better data look like? It starts with combining EHR and payer reimbursement and then supplementing it with additional data sources. The hybrid data set is then "normalized" and put into a single data warehouse.

2) Yes, but more and better data won't go far without insights.

Even with this expanded data approach, data are still just a means to an end. Insights must be derived from that data in real time in order to be useful and trigger an action on behalf of a care provider. Data captured in a report format won't have nearly the impact of data delivered directly into the care continuum. Actionable insights available to providers during a real patient interaction help to avoid readmissions and close care gaps.

3) We need to understand the total health of the patient.

A million joint replacement surgeries were performed in the US in 2010, the last year such data were available from the CDC. A joint replacement patient with comorbidities such as hypertension or diabetes needs a different care plan than the weekend athlete whose knees finally give out. That translates into different post-surgery monitoring, different medication, different everything. Making sure these care plans are understood and followed by all providers is vital to curbing readmissions.

4) Let's get primary care involved and make sure they have the right tools, data and support they need to succeed.
Primary care providers need a technology platform that generates the right data in the right combinations as part of the care delivery process. That platform should include:

• EHRs - Making sure PCPs are maximizing the capabilities of electronic health records to track patients and making sure they get the preventive care they need to forestall a hospital admission.

• Telemonitoring to support the care continuum after discharge - Telemonitoring of heart failure patients, as outlined in a Geisinger Health Plan study, helped alert case managers almost immediately when biometric measurements fell outside a specific range. This enables case managers to better identify pre-acute situations that can be addressed in the least costly and most effective care venues, namely the home or doctor's office.

• Patient digital services - According to a recent study by Technology Advice, less than a third of patients say their physician offered digital services. The majority of patients want their PCP to offer – at the very least - online scheduling, appointment reminders and the ability to refill prescriptions. These digital services help smooth workflows and keep patients compliant with their care plan.

5) Why not explore at-risk contracting?

Avoiding penalties as well as increasing revenue through at-risk contracting are ways in which an Integrated Delivery Network (IDN) can improve the health of a population in general and after a hospital stay.

But to drive more value from value-based care, incentives must be supported with the right tools, team and process improvements that benefit readmission objectives as well as quality and satisfaction.

Mark Crockett is the CEO of Rise Health, a Best Doctors company. He also practices emergency medicine at Advocate Good Samaritan Hospital in Downer's Grove, Ill., is a published author and a fellow of the American College of Emergency Physicians.

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