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

And that’s just the Medicare population.

The causes of readmissions can be understandably complex. But in our experience at Carenet Health, most avoidable rehospitalizations can be linked to at least one of these contributing factors:

  • Complications, like infections, arising from the initial hospital stay and poor post-discharge care
  • Recurrence of a chronic condition that led to the initial hospitalization
  • Confusing discharge procedures and issues with medication reconciliation
  • Lack of care transition management and follow-up communications
  • Limitations of care-giving support at home
  • Issues with nutrition, transportation, childcare and other social determinants of health (SDOH)

Tackling readmissions with patient engagement

Reducing preventable readmissions requires a systemwide, multifaceted approach, and patient outreach is an absolutely critical component. Following are three strategic areas that can help your organization, whether it’s a hospital or health plan, start to lower those avoidable readmission numbers right away.

1. Post-discharge support

Regardless if a hospital stay lasts two days or two weeks, discharged patients often leave feeling exhausted and overwhelmed from the experience and confused about how to care for themselves at home, comply with post-discharge instructions and obtain the necessary follow-up care.

The good news is there are proven engagement best practices for post-discharge support in the first 30 days that can help. Key best practices include:

  • Implement multiple touchpoints to reinforce care instructions and discuss treatment adherence
  • Counsel and educate not only patients, but also family members and other caregivers
  • Plan for data-driven outreach to monitor conditions with traditionally high readmission rates
  • Use clinical support to identify and triage issues before they advance
  • Coordinate follow-up visits with primary care providers and specialists
  • Communicate the availability of resources such as a nurse advice line or other telehealth options
  • Enroll patients in disease or case management programs within an appropriate timeframe after their discharge
  • Directly ask about and address patient and caregiver questions, concerns, fears and misconceptions
  • Ask about and address SDOH factors
  • Recommend and reward positive behavior

The bad news is that most providers and payers only leverage one or two of these tactics. With a more holistic approach, readmissions rates will decrease, and the increased engagement can pay for itself.

2. Medication management

Medication management and reconciliation should play a substantial role in any successful post-discharge support solution—because a large portion of hospital readmissions every year are due to drug-related adverse events, many of which are preventable.

Addressing medication management with patients immediately following discharge is absolutely imperative, but there is also a need for improved medication adherence monitoring throughout the continuum of care. This is especially true for patients taking numerous medications for multiple chronic conditions.

Proactive measures to improve medication adherence include:

  • Outreach that includes adherence importance and non-adherence risks, strategies for remaining compliant, and the addressing of individual concerns and misconceptions.
  • Drug-switch programs in which patients are advised on the cost-saving benefits of generic drugs and seamlessly switched from brand-name drug prescriptions to generic equivalents
  • Mail-order pharmacy enrollment, which allows for additional savings and the convenience of receiving a 90-day supply via home delivery

Case in point: A top commercial health plan collaborated with Carenet to educate its members on cost-savings provided by switching from a brand-name statin to a generic one. More than 60% of the contacted members made the switch. The program produced an annual savings of $4.7 million for the plan and $1.1 million for members.

3. Telehealth care

From remote patient monitoring to patient-clinician video consults, telehealth is increasing in importance in preventing avoidable hospital readmissions. By offering a range of telehealth services (preferably with no copay) during the critical 30-day discharge window and year-round for patients with chronic conditions, payers and providers alike can reduce readmissions while elevating outcomes and satisfaction.

A comprehensive virtual care plan would feature resources such as:

  • Health advocates, also called care navigators, who can facilitate care access
  • On-demand, 24/7 telehealth support from registered nurses, physicians and behavioral health specialists
  • The ability for patients to consult with healthcare professionals using their preferred method of communication from any location

Case in point: In one year, a pilot program offering remote video consultations between nurses and discharged hospital patients cut readmissions by a remarkable 75%.

Readmissions program design doesn’t have to be complicated

Reducing avoidable readmissions make take a multipart plan, but that plan doesn’t have to be difficult to put in place. At Carenet, we have decades of experience developing and implementing holistic and patient-centric solutions that help our clients decrease readmissions, elevate patient well-being and boost provider and plan performance.

By removing many of the obstacles and silos that lead to unnecessary re-hospitalizations, we can cost-effectively help your organization empower patients and enable care teams to collaborate for shared success.

We’re here to brainstorm ideas with you any time.