Healthcare organizations must place a high priority on patient engagement through risk assessment, caregiver education, and addressing social determinants of health in order to effectively minimize hospital readmissions (SDOH). Identifying high-risk patients, involving patients and families throughout care transitions, and ensuring thorough follow-up after release are all essential components of effective programs. In order to help patients recover, proactive approaches like outreach and remote patient monitoring are crucial. Understanding how SDOH affects readmission rates is essential because it drives the need for customized engagement initiatives that will reduce these obstacles and improve care quality while lowering costs.
Healthcare organizations must take a multifaceted approach to prevent hospital readmissions, encompassing risk assessment, patient engagement, caregiver education, and addressing social determinants of health (SDOH).
Achieving favorable hospital readmission rates hinges on the implementation of a well-crafted patient engagement strategy.
Hospital readmission rates are a critical metric in value-based care models, reflecting the proportion of patients returning to the hospital within specified timeframes, with a primary focus on the 30-day all-cause readmission rate for payment models.
The Hospital Readmission Reduction Program (HRRP), initiated by CMS in 2010 as part of the Affordable Care Act, initially reduced readmissions but has since plateaued. Risk-adjusted data, however, continues to show a decline in rates.
Nonetheless, there is room for improvement. In 2018, there were 3.8 million 30-day all-cause adult hospital readmissions, with a 14 percent readmission rate costing approximately $15,200 per readmission, according to a 2021 report from the Joint Commission.
Reducing hospital readmissions is a complex endeavor that relies on various factors. In addition to delivering high-quality care, healthcare providers must motivate patients to engage in post-discharge care management and ensure that their condition does not deteriorate unexpectedly.
Effective patient engagement strategies include identifying high-risk patients, involving them in the care planning process, ensuring robust patient follow-up, and addressing SDOH.
Identifying High-Risk Patients:
Healthcare professionals must initially identify patients at the highest risk of medical complications during recovery, allowing for targeted engagement efforts.
Conditions with the highest readmission rates in 2018, as per the Joint Commission report, included septicemia, heart failure, diabetes mellitus with complications, chronic obstructive pulmonary disease, and pneumonia. Beyond medical conditions, sociodemographic factors, such as limited English proficiency and race, can also increase readmission risk. Patients facing SDOH challenges, like transportation access or food insecurity, may struggle to adhere to post-discharge plans.
Low-income patients and those with low activation scores are also at risk. Healthcare organizations can tailor post-discharge follow-up plans accordingly, considering SDOH factors and engaging patients and families to reduce readmission risk.
Engage Patients and Families in Transitions of Care:
Engaging patients and their families during the discharge process is crucial for ensuring successful recovery, particularly when transitioning to home care.
Discharged patients may go to various settings, including rehabilitation facilities, skilled nursing facilities (SNFs), or home care. Patient and family engagement is vital, especially for home care, where patients and caregivers take on care management responsibilities.
Effective discharge planning is essential, as the transition from hospital to home can be complex and overwhelming for patients and families. Engaging patients during care transitions ensures that care plans align with patient preferences and that patients and caregivers understand their illness, medications, and care management plans.
Research indicates that patients who are actively involved in care planning and follow-up have better outcomes. Focusing on care coordination, medication management, and caregiver education during the discharge process can improve hospital readmission rates.
Healthcare providers should begin the discharge process before the patient leaves the hospital, with continuous patient education. Strategies like patient teach-back enhance education and understanding. Involving various care team members, such as nurses, pharmacists, and physicians, is also critical for tailored patient education. Patient discharge checklists can further streamline the process.
Notably, involving family caregivers can reduce readmission rates by around 25 percent, emphasizing the importance of their engagement during discharge. Connecting caregivers to community healthcare resources, providing written care plans, and using patient teach-back and at-home procedure demonstrations can help engage caregivers effectively.
Follow-Up Patient Engagement and Outreach:
Preventing hospital readmissions extends beyond discharge; clinicians must continue to guide patients in care management during recovery, whether at an SNF, rehab facility, or home.
Remote patient monitoring technology can support care management, as evidenced by home blood pressure monitoring systems that help prevent readmissions. Remote monitoring systems also aid in early intervention by predicting readmissions.
Patient outreach is another essential component, allowing healthcare providers to advise patients on care management plans, address questions, and monitor recovery progress. Outreach can involve phone calls, text messages, patient portal messages, or clinician communication.
Regardless of the medium used, these outreach efforts help patients adhere to post-acute care plans and identify acute issues early, reducing emergency department visits and hospital readmissions.
Automated SMS outreach, in particular, has shown promise in reducing readmission risk. By reminding patients of care management plans and collecting recovery information, this method cut 30-day hospital readmission risk by 41 percent, according to a 2022 JAMA Network Open report.
Addressing Social Determinants of Health (SDOH):
SDOH significantly impacts hospital readmissions, affecting patient access to care and self-management at home. Identifying the link between SDOH and readmission rates is essential.
Barriers such as transportation access, food insecurity, and limited access to nutritious food can impede recovery. Hospitals should remain aware of the SDOH-readmission connection and create patient engagement programs that address these factors. Screening and data collection can help identify prevalent SDOH in their patient population, leading to organizational interventions.
SDOH screening can also identify individual-level interventions to mitigate SDOH-related barriers, aiding care coordinators and patient navigators.
Reducing hospital readmissions remains a top priority in healthcare, and strong patient engagement strategies during the post-discharge phase are crucial in minimizing costly readmissions.
