Reducing Readmissions with a Call

Bundle payments. Value-based care. Population health. SDOH. Patient engagement. Patient centric care. Transitions of Care. Standardization. Systemness. Integrated delivery system. Readmission risk score. Predictive analytics. Patient progression. High reliability. High impact. Employee engagement. So many buzzwords fill our days and thoughts. All real. All important. What is the most important? What is it all about? Where do we start first? Makes your head spin.

If it makes our head spin, just think what it does to the patient and family members. Maybe that’s where we start. You say, “Well, all impact the patient.” Correct. All impact the patient either directly or indirectly. So then maybe we need to look at like a triangle. What small changes or process improvements can we implement that will have the greatest positive impact on our patients and the most patients at the same time? A Chief Medical Officer once said to me said, “What one thing can we do to help the masses on an individual basis?” Because isn’t that what it’s all about—the patient?

I know this seems simplistic, but it works. Let’s look at one issue. High readmission rates. What have you done in the past? What are you doing now? How have you involved the patient? What are some of your peers doing? What is one thing you could implement to prevent avoidable readmissions? Follow up appointments? Contact with the patient’s medical home? Rides to and from follow up appointment? Follow up appointments within three to five days? (Yep, I said it—three to five days.) Follow up phone calls? Educating the family members on the post hospitalization follow up?

Ah, what about this? Making phone calls prior to hospitalization so the patient and family know what to expect while hospitalized. During this call, the case manager educates them on what to expect from admission to post-hospital care. Granted not every patient or family member can be called. However, it is amazing when the initial touch occurs prior to the hospitalization. It gets the patient and family members involved in the plan of care upfront. They can ask questions and learn. It minimizes their anxieties. We know that when there is greater patient engagement, readmission risk decreases. It, also, gives the case manager, the opportunity to be proactive. During the call, the case manager can start assessing the patient’s needs and planning for them prior to discharge! It potentially decreases the required initial assessment work done by the case manager. Now wouldn’t that be a good time saving idea?

Hmm, this one solution checks off several of those buzzwords while focusing on the most important factor---the patient. Good luck. Let me know how it works out for you.