Part 1: Preventing Hospital Readmissions with Care Management outlined how reducing hospital readmissions helps improve both patient care and patient satisfaction, and lessens the chance that healthcare organizations will be penalized by Medicare. The conversation continues with a look at how care management programs can help hospitals intervene with high-risk patient groups to reduce hospital readmissions.

3 steps to prevent hospital readmissions

Care Management Provides a Holistic View of the Patient

Establishing a care management program allows hospitals to coordinate care delivery, interventions and education for its most vulnerable patient populations. For most hospitals, following up with discharged patients presents a significant resource issue. Nurses try to contact recently discharged patients between other tasks, as time allows – and it often doesn't.

By stratifying the population, hospitals can focus their efforts on patients with multiple chronic conditions, the elderly and patients recovering from high-risk procedures for which they are more likely to develop a subsequent infection or complication. Even with limited resources, hospitals can still have an immediate impact on reducing hospital readmission rates if they concentrate clinical attention on these high-risk groups.

Some care management solutions use evidence-based clinical assessments and integrated care plans. These solutions recognize patients with multiple conditions, compiling all relevant questions into one blended assessment, minimizing staff resources and helping care managers to better manage high-risk, complex cases.

As research indicates that more than 25% of all readmissions within 30 days of discharge are for conditions unrelated to the initial admission1, a holistic approach to post-discharge follow up is particularly important for preventing readmissions. For high-risk patients with multiple chronic conditions, the nurse needs to know the full spectrum of the patient's medical history in order not to miss opportunities to treat other conditions that pose a re-hospitalization risk.

Learn more about how care management software solutions can help you manage high-risk conditions and complex cases to help prevent hospital readmissions and improve patient outcomes.

Clinical Alerts Guide Follow-up Contact

Reducing hospital readmission rates becomes much easier when care managers are guided by clinical intelligence present in the patient's care plan. Along with information on what happened during the patient's hospital stay, a good clinical assessment will also include the patient's medical history, current medications, discharge instructions and key lab results.

By standardizing contact with the patient post-discharge, the hospital can establish clinical protocols that outline best practices for reducing readmissions. With ready access to the patient's discharge instructions, the nurse or care manager can provide another copy for patients who have lost the original. Evidence-based educational tools help nurses or care managers interact successfully with discharged patients, as they are well-informed about not only best practices but also the patient's history. Care managers can discuss the meaning of lab results, explain the reasoning for a particular prescription, or educate the patient on his conditions. All information regarding contact between the patients and their providers is registered in the system, so a clear history is available at all times.

In addition to prompting initial contact with the patient within the first week post-discharge, some care management workflow and documentation solutions generate clinical alerts when gaps in care are found. Care managers are to follow up with patients to pinpoint any challenges and determine support to overcome these obstacles. Helping patients become successful after their hospitalization is not easy work, but with the right process and workflow tools, hospitals can achieve declining readmission rates and improve the quality of the patient care they deliver.

Read more about how care management software solutions can help your organization better manage high-risk patients with multiple chronic conditions to reduce hospital readmissions and improve patient outcomes.

1"Physician Visits after Hospital Discharge: Implications for Reducing Readmissions". National Institute for Healthcare Reform. December 2011. Accessed December 5, 2014.

Andrew Herrick

About the author

Andy Herrick is Director of Product Strategy for McKesson Population Health Management solutions. With over 20 years of healthcare experience, Andy has also directed employee wellness programs and served as a faculty member for the School of Professional Studies at Fresno Pacific University. He holds a double B.A. Natural Science and Health Education from Fresno Pacific University and a Ph.D. in Wellness Education from Arizona State University. He is also a Certified Health Education Specialist.