Care Transition - Readmissions
Readmission to the hospital within 30 days of discharge has become an important measure of quality of care, and is a major focus in Medicare’s attempt to control rising healthcare costs.
Frequent contact with post-discharge patients invites opportunities to detect early symptom change, thus earlier
intervention. Early intervention can play a significant role in simpler, more effective treatment to help prevent hospital readmission.
The period of time following patient discharge from hospital often represents a “blind spot” in the overall coordination of care.
Patient responsibility is often ambiguous. Discharged patients are often confused about symptoms, post-discharge instructions
and/or medication regimens, which can result in early readmission. Effective post-discharge patient monitoring can facilitate
care coordination at this juncture but such programs can be very costly.
Automated calls based on disease or condition-specific scripts ensure uniform adherence to the script. Contact scheduling
requires minimal involvement from hospital IT departments. Patient responses can be transmitted in a variety of formats to
appropriate staff, tailored to each hospital’s needs. As a result the hospital has the opportunity to identify the patients
who indicate trouble before hospital readmission is necessary.
Policy makers and industry experts in the battle to stem rising health care costs have made focal points of hospital readmissions,
and specifically heart failure readmissions.
Medicare has identified readmission to a hospital within 30 days of discharge as a major contributor to excessive cost in the Medicare program.
Of patients admitted for heart failure, approximately one-third will be readmitted within 30 days. MedPAC has recommended a reduced reimbursement
for these 30-day readmissions, while Medicare reimbursement for many conditions including heart failure often fail to meet many hospitals’ current costs.
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OutcomeAdvantage Media Center
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