When a patient is discharged from a hospital, the discharge planning nurse should probably end the conversation with the patient by saying, “Best wishes and we will see you in a couple of weeks.”
One in five elderly patients makes a return trip to the hospital less than a month after initial discharge. Called the revolving door syndrome in a report conducted by the Robert Wood Johnson Foundation, titled Care About Your Care, the frequent return trips to the hospital come with a $26 billion price tag annually for Medicare patients. The report goes on to say 65 percent of the total cost could be prevented if hospitals tweaked their system of care.
Too often patients do not comprehend the doctor’s instructions prior to leaving the hospital. The end result is poor medication adherence and failure to get the proper follow-up care.
A key to cutting down the number of readmissions is to identify patients most at risk of returning to the hospital. It is impossible to have a readmission program targeting every patient. Too much energy is wasted and the program is rendered ineffective.
Considering 80 percent of all readmissions come from 20 percent or less of the same patients, it is paramount hospitals identify those patients and implement programs to prevent readmissions.
An effective way of identifying high-risk readmissions is a health risk assessment (HRA) and continued communication with the patient to bolster patient engagement. MDnetSolutions has developed a digital HRA form that is easy to use and can be accessed online. HRAs can determine the current status of a patient’s health, estimate the level of health risk involved with a procedure, and more importantly, inform and provide feedback to patients via online reports.
The patient, or his or her caregiver, can access these online reports and continue the personalized care that hopefully will prevent the patient from returning to the hospital.
Identifying the Need for Intervention
In addition to MDnetSolutions’ HRA program, the Atlanta-based company also has increased its ability to help hospitals transform patient care and remain actively engaged with the patient following discharge by acquiring IVR Care transition Systems, which excels in providing support for patients making the transition from the hospital to home.
Using an interactive voice response telephone system and carefully developing surveys, or HRAs, members of the IVR care team, which is available to hospitals, gather vital information from the patients’ responses to the assessment.
These responses can identify early signs and symptoms of clinical problems or issues with medication adherence and the need for follow-up care after hospital discharge.
The results of the HRAs are sent to the healthcare team at the hospital on a daily basis, and if warranted, the healthcare professional will follow up with the patient with a phone call. This provides an opportunity to identify a problem before it turns into a serious condition, requiring a return trip to the hospital and costing both the patient and the facility money.
In the long run, using the patient engagement solutions created by MDnetSolutions is a win for patients, who receive quality, personalized healthcare and for the hospitals that save on patient readmissions.