Reducing Readmissions: Managing Care Transitions

An avoidable readmission to a hospital or skilled nursing facility (SNF) is a frustrating and expensive experience for patients and families, and is increasingly viewed as a failure to provide patient-centered care.  Among the interventions that have been shown to reduce avoidable readmissions include:

• Contact patients deemed to be “at risk” for readmission within 48 hours of discharge (earlier, if possible): Contact by phone to assess their understanding of their condition, medications, and other self-care needs. Intervene (schedule a visit, order a home nursing visit, etc.) if the patient seems unsafe.
• Schedule a visit with the primary care physician within 3 – 7 days after discharge: Research has shown that the risk of 30-day readmission for patients deemed “at risk” for readmission to a facility is significantly reduced when they are seen by a physician (primary care or, in some cases, specialist) within 3 – 7 days of discharge. 30-day readmission rates are being tracked by health plans for individual providers and for hospitals and SNFs, so all parties have incentives to reduce unnecessary readmissions.  In the Grove Hill branch, a nurse contacts “at risk” patients within 48 hours of discharge, assesses their status and safety, and assures that the patient has an appointment to see their PCP within 7 days of discharge.
• Home care: Patients who transition to home without home care services may realize after they have gone home that they need help managing their own care. As our practice becomes more effective at managing readmissions, we may wish to offer to pay for a home care visit in selected cases in order to avoid a costly readmission, which will be captured as part of the Starling “cost of care” for our attributed members.
• Longer term: While Starling is making inroads in managing the cost of readmissions, ER utilization and generic prescribing, we also need to be planning to deliver care in lower cost locations (e.g., practice-owned surgery centers and infusion centers) in place of higher cost hospital-owned outpatient facilities.