Addressing post-acute readmissions

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Greg Borecki
Greg Borecki

Readmissions continue to be a barometer of patient engagement and value-based care for the nation's health systems. Since the introduction of HRRP (Hospital Readmission Reduction Program, Oct. 1st, 2012), hospitals that exceeded the national average have been penalized by a reduction of payments across all of their Medicare admissions. The HRRP penalties in 2017 (calculated based on three full years of hospital data between 2012 -2015) hit a cumulative of $528M in readmission penalties which was assessed on approximately 1/3 of the hospitals across the nation.

Medicare reports that of 35 million patients discharged from U.S. health systems, about 20% of them return within the 30 days. Many of the issues surrounding readmissions within 30 days have been analyzed, and facilities use discharge documentation, post-acute treatment nurse calls to the home, and models like the LACE index to help identify patients at risk of readmissions. Fortunately the numbers related to readmission penalties have been reduced; unfortunately the penalties, total cost of readmissions, and the poor public relations that result from readmissions has continued to grow.

When you add the significant growth of the 55 or older population, and the fact that the Agency for Healthcare Research and Quality reports that ¾ of hospitalized patients return to home, there is an opportunity to shift the nature of patient engagement and reduce the costs, penalties and numbers that lead to Post-Acute readmissions.

The patient need not disappear

Today, most post-treatment release scenarios include the immediate exchange of patient discharge information/documentation with the potential of a follow-up call by the discharge administrator or nurse. Unfortunately, health systems typically have no processes or technology that would allow for continuous engagement outside of the discharge documents and a patient portal. Currently, the patient effectively disappears from the hospital view and the 30 day readmission clock starts. Care continuity is broken since the hospital has no idea what is happening outside its walls. In addition, aftercare providers are usually not connected to the hospital in any way, resulting in more fragmented care delivery.

                                                                                       Infographic 1- Provided by LifeAssist


As the patient returns home, the responsibilities of care are transferred to the family, professional caregivers and community resources surrounding an in-home recovery. During the post-acute care transition, a crucial step is being mismanaged and the connection between hospital, patient, family and caregivers is broken. This results in various failed handoffs, impacting the quality and quantity of post-acute care delivery. At discharge, the integration of post-release caregivers into a successful care journey and planning process is necessary to ensure continuity of care. There is a cascade of problematic and related issues that stem from silos of people and data being created and disconnections of communication between the participating caregivers and true patient engagement. (Infographic 1) 

Coordination and collaboration across the care circle is particularly important with older patients where the mismanagement of medication and nonadherence to therapies and rehabilitation activities is a top reason for readmissions. The Journal of American Geriatric Society recently conducted analysis that revealed a 25% reduction in readmissions when utilizing programs to include and integrate discharge practices with spouses and family members. 1

Adults 65 and older visited the emergency room 20.8 million times in 2013, this was up from 16.2 million in 2000, according to the Centers for Disease Control and Prevention. The survey found 1 in 6 visits to the ER were made by an older patient. Since the population of patients aged 65 and over is projected to grow to 80+ million by 2050, there will to be significant changes in how the post-acute care community connects and shares data to provide coordinated care, and develop predictive capabilities to reduce readmissions and associated costs of care delivery.

Technology is assisting and promoting patient care and engagement. A Mayo Clinic study  found that devices (mobile, in-home sensors, remote monitoring) for cardiac rehabilitation patients (one of the largest and most costly groups  in HRRP's Readmission Penalty categories) had a 40% decrease in readmissions per their utilization of technology to record, monitor and report  daily healthcare data and activities. That is indicative of a technology deployment trend which we believe will continue to grow. 2   

The technology emerging in order to be effective and adopted, must be engaging, very easy to use and allows for the robust sharing of data. In addition to creating collaborative environments for caregivers it must also empower the patient to be involved, self-reliant, self-reporting as they provide real-time feedback to a care circle on their symptoms, nutrition, activities and medical adherence. Technology in, and out of, the home is creating high visibility and engagement across a patient's care journey and enhancing the communication and collaboration that strengthens  human linkages, enables care continuity, and reduces  avoidable readmissions.


Greg Borecki is the vice president of Senior Living & Fall Management at STANLEY Healthcare. Val Ornoy is the CEO of LifeAssist Technologies.

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