3 Key Post-Acute Partnerships that Reduce Readmissions

Wednesday, January 22nd, 2014
This post was written by Cheryl Miller

Developing post-acute partnerships with home health organizations is one of the three top ways healthcare professionals are seeking to reduce readmissions, according to more than half of the respondents to the Healthcare Intelligence Network’s fourth comprehensive Reducing Hospital Readmissions Benchmark Survey.

Almost three-fourths (67 percent) cited skilled nursing facilities (SNFs) as their preferred post-acute partner, and 50 percent said they were partnering with hospices to reduce readmissions.

Other partnerships cited included telemedicine, free/low cost clinics, physician networks, and transitional care programs.

Among other key facts:

  • Nearly all of the respondents said that partnering with post acute providers helped them to streamline processes, educate their staff, and implement effective changes of value to the patient.
  • Among respondents from hospital systems (42 percent) that partnered with home health organizations, identifying high risk individuals most likely to be readmitted post-discharge and communicating this information to providers was key to successfully averting readmissions. Involving the patient’s designated caregivers in follow-up dialogues and transactions also improved the odds of prevention.
  • In addition to post-acute correspondence with their home health organization within 24 hours of discharge, one hospital system also practiced medication reconciliation and education and physician scheduling.
  • Follow-up appointments for patients with their home health and/or SNF provider within seven days for Medicare and Medicaid patients with no primary care doctor factored into one hospital system’s readmissions prevention plan. Assuring that medication reconciliation information was made available to their post discharge providers, particularly for high risk utilizers, was also critical to prevention.
  • A hospital system that partnered with low-cost clinics in addition to home health organizations maintained daily and weekly telephonic education meetings with patients, coordinated by its diabetes disease management nurse, diabetes educator and clinical pharmacist.

The ultimate goal in partnering with post-acute providers was to engage with patients while in their facility and continue to follow up with them upon discharge, with continued education and teach back as well as monitoring and overseeing their patients’ progress.

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