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Post-Discharge Strategy Addressing Social Determinants of Health


More than half of the nation’s hospitals are being penalized a total of $564 million in FY 2018 by the Centers for Medicare and Medicaid Services (CMS) for excessive Medicare patient readmissions within 30 days of discharge.

A $27 million increase over 2017, this is the highest amount fined since the enactment of the Hospital Readmissions Reduction Program (HRRP) five years ago. Although national readmission rates have declined under the HRRP, they remain an all too common and costly problem.

Nearly one in five Medicare patients return to the hospital within 30 days of discharge and many more end up in the ER, says CMS. It’s estimated that readmissions for Medicare patients cost $26 billion a year, of which an estimated $17 billion comes from potentially preventable rehospitalizations.

Readmission Drivers
Multiple factors contribute to readmissions, from premature discharge and confusing discharge procedures to caregiver limitations, patient nonadherence and inadequate follow-up care.

Social determinants of health, such as income and education level, living conditions, food supply and support networks, also play a significant role.

One major complaint of the HRRP since its introduction is that CMS doesn’t adjust readmission rates for socioeconomic factors. This means safety-net hospitals that treat high-risk populations, including dual-eligible beneficiaries, are disproportionately penalized.

CMS began to address this issue last year with a provision in the 21st Century Cures Act that requires Medicare to account for patient backgrounds when calculating readmission penalties. Starting in October 2018, a hospital’s performance will be compared to other hospitals with a similar percentage of dual-eligible patients. However, despite this initiative, CMS predicts the decrease in penalties will be minimal.

More Effective Methods Needed
While the provision is a step in the right direction toward lowering hospital fines, it doesn’t address the critical need for more effective methods for helping discharged patients overcome their socioeconomic barriers to care so they don’t land back in the hospital.

“Despite a greater emphasis on the implications of social determinants of health, readmission screening tools and discharge planning strategies do not adequately address these social dilemmas,” says Jennie Echols, PhD, MSN, RN, Director of Clinical Solution Development at Carenet Healthcare Services. “Addressing a patient’s health-related social needs is a key component of our post-discharge solution.”

Social Determinants Emphasis
By personally supporting a patient’s transition from a hospital or outpatient care to home, Carenet’s high-touch post-discharge solution helps ensure engagement, adherence and safety—and a smoother road to recovery.

Our highly skilled team proactively engages with patients and their caregivers throughout the critical 30-day post-discharge window. Emphasis is placed on assessing the social determinants of health that contribute to readmissions.

“Many people discharged from the hospital can’t afford to pay for medications, healthy food or utilities, don’t have a stable housing situation, or lack transportation to attend follow-up appointments, ultimately leading to rehospitalizations,” says Echols.

Carenet’s determinants assessment covers:

  • Housing and utilities: affordable housing and safe living conditions, including utilities (e.g., water, electricity, gas, phone)
  • Social supports: availability of family and friends to provide recovery support
  • Food: access to affordable, nutritious food, including appropriate food for medical condition management
  • Medication management: ability to obtain and self-administer prescribed medications
  • Transportation: affordable, reliable means to access medical appointments, pharmacies, grocery stores, etc.

Based on this assessment, plus an evaluation of the patient’s health literacy level and capacity to manage his or her recovery and condition, Carenet’s post-discharge specialists perform the following services as needed:

  • Address socioeconomic barriers uncovered during the assessment and assist the patient with overcoming them (e.g., provide a referral to meal delivery or transportation services)
  • Discuss discharge instructions ensuring patient understanding
  • Review prescribed medications confirming attainment and patient comprehension of treatment plan
  • Refer the patient to a pharmacist if there are missing medications or questions regarding the prescribed regimen
  • Confirm follow-up appointments have been scheduled and verify appointments were kept; if not, assist with the initial scheduling or required rescheduling
  • Communicate resources, such as Carenet’s 24×7 Virtual Clinic Nurse Advice Line
  • Make appropriate referrals to available services such as case management or condition/disease management
  • Monitor conditions with traditionally high readmission rates
  • Identify and triage issues before they advance
  • Address patient and caregiver questions, concerns, fears and misconceptions

Carenet’s post-discharge support solution substantially decreases preventable readmissions that take a toll on patients and their families, divert limited resources, elicit hospital penalties and increase America’s healthcare bill.

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