Hospital readmissions, defined as patient's presentation to the hospital within a specified period after discharge, continue to be significant challenge across healthcare systems nationwide. Readmissions contribute to increased healthcare costs, suboptimal patient outcomes, complex transition of care, and poor patient experience. Health systems, innovative primary care groups and payers have tried to address readmissions through different programs and initiatives. One promising strategy is shifting care into the home.
In a recent study conducted by Becker's and 黑料门, 55% of organizations with care at home programs said they have realized improvement in hospital readmissions. 66% of programs in this study were less than 5yrs old and 41% were 0-2yrs old.
Care at home programs allow certain patients to receive care in the home as an alternative to brick-and-mortar care. This can include a combination of clinical services, remote monitoring, and coordination of care to improve clinical outcomes and transition of care.
One of the key drivers of hospital readmissions is the lack of adequate support and monitoring during the transition period from hospital to the outpatient setting. During this period, patients discharged from the hospital often face challenges in managing their conditions with confusing post-discharge care plans and delayed outpatient follow-up. With complex medication regimens and limited support, patients are at risk for clinical decline leading to preventable readmissions. Well-designed care at home solutions address these gaps, also referred to as transitions of care, by providing patients with access to remote monitoring, virtual clinical teams, and personalized care plans.
Wellstar MCG Health has demonstrated readmission rates of 7% for their care at home program, which includes 14 common medical conditions, significantly lower than the national average.
Remote monitoring plays a crucial role in preventing hospital readmissions by enabling healthcare providers to track patients' vital signs, symptoms, and adherence to care plans. Advanced monitoring devices and wearable technologies all for real-time data collection and analysis via continuous and episodic monitoring and patient submitted data, empowering healthcare teams to intervene remotely. By appropriately monitoring patients' health status and identifying potential concerns early on, healthcare providers can proactively prevent complications and avoid unnecessary hospitalizations before they occur.
Virtual clinical teams accessible to the patient-on-demand make it easier address patient concerns and provide interventions when necessary. This prevents from having to go to a brick-and-mortar facility for evaluation and preserves continuity of care with one, virtual care team.
Learn how one hospital system was able to demonstrate a significantly reduced 30-day hospital readmission rate with their care at home strategy as compared to their traditional brick and mortar 30-day readmission rate of 16-17%. Read here.
Care at home programs can include robust technology platforms that facilitate care in the home. This can include virtual communication tools to conduct virtual visits, in-home ancillary service coordination, remote monitoring, task management and inventory tracking. These technology solutions reduce barriers to care and make care delivery easier for providers and patients. Additional tools such as personalized care plans that are disease- and patient- specific and machine learning algorithms which can surface clinical insights from vast amounts of biometric data can improve clinical management as well as patient and provider experience.
Hospital readmissions also contribute significantly to healthcare expenditures, by placing a substantial financial burden on healthcare providers, payers, and patients alike. By preventing unnecessary hospitalizations and promoting more efficient use of healthcare resources, care at home solutions can help contain costs while improving the overall quality of care.
An average readmission cost of $15,200 per patient2
In conclusion, reducing hospital readmissions is a complex but critical challenge that requires innovative approaches to care delivery. Care at home solutions offer a promising strategy for addressing this challenge by providing patients and clinicians with the operational and logistical support, monitoring technology, and personalized care to manage patients effectively at home and to reduce the rate of hospital readmissions.
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