What are the key factors associated with high readmission rates?
Health Conditions/Comorbidities
Mental Health
Patient Disengagement & Non-Compliance
Social Determinants of Health
Health Literacy
Patient Education
Medication Errors
Care Coordination/Timely Follow up
Cost
Strategies that can prevent/minimize readmissions
Data Analytics
Patient Education & Family Engagement
Electronic Health Records
Care Coordination among all systems
Build Multidisciplinary teams
Make accurate diagnosis
Identify root causes
Establish feedback loops
Address other comorbidites
Secondary Drivers
Create a patient-centered record.
Timely communication with members of the care team who are not hospital-based.
Accurate medication reconciliation at admission, at any change in level of care, and at discharge.
Follow-up
Secondary Drivers
Coordination with physician/other care provider to facilitate resources and follow-up needs.
Post discharge calls/visits for high-risk patients.
Integration of organizations and identify or develop medical home capabilities.
Determine the community resources for the special needs of the highly vulnerable populations.
Patient and caregiver involvement in post-discharge planning.
Secondary Drivers
Effective risk assessment and simplified risk stratification
Enhanced admission assessment of discharge needs
Engage a multi-disciplinary team to coordinate care.
Secondary Drivers
Enhance patients’/caregivers’ knowledge about the medications prescribed.
Enhance patients’/caregivers’ knowledge about their symptoms, red flags, and self-care strategies.
Identify and address patients’ health literacy and activation levels.
Use Teach-back to validate patient understanding.
Can help improve a patient’s medication compliance following discharge
Post Discharge coordination of care
Patient Education
Proper hand off & Communication between clinical care teams
Partnerships with community service providers can facilitate the transition of patients back into the community and ensure continuity of care for patients following hospitalization
Lack of insurance
Patient's can't afford medication
Diabetes
Depression
Anxiety
Hypertension
Population Health
Hospital Operations & Leadership
Setting the mission & value
Enabling team members & reducing barriers
Coordination across the care continuum
Developing local & community approaches to healthcare
Language barries
Research Method
Case Study
Most Common: CHF/COPD
Plan is to interview various team members that would be involved with those patients and create a timeline from admission to discharge and beyond to readmission.