The Guide to Reducing Readmissions

To avoid leaving reimbursement money on the table, healthcare organizations are working hard to reduce avoidable rehospitalizations, especially among Medicare patients. Healthcare reform legislation provides further motivation by offering incentives for programs that improve the efficiency and affordability of the healthcare system. The Guide to Reducing Readmissions examines eight top tactics that healthcare organizations are using to reduce readmissions, according to responses to the Healthcare Intelligence Network 2010 survey on Reducing Readmissions. Learn how early adopters are utilizing these tactics to empower patients and improve the quality of healthcare delivery.

Don't wait to order your organization's copy of The Guide to Reducing Readmissions and incorporate the best practices, strategies and innovations that top healthcare organizations are using to prevent avoidable rehospitalizations.

The Guide to Reducing Readmissions includes:

- Readmission reduction strategies and tools, as well as benefits, barriers and results;
- Details about selecting, training and employing a case manager;
- Data on using care transition to enhance care coordination, as well as the role of the medical home in care transition;
- Ways to promote successful discharges and handoffs and link transitional care efforts with case management;
- Key roles of technology, such as telephonic monitoring, relating to patient discharge;
- Ways to achieve medication adherence through an integrated care team, use home visits to prevent avoidable readmissions and implement health coaching programs;
- Specific examples of industry experts’ team based approaches and provider-patient communications;
- Key indicators to identify high-risk patients and ways to close gaps in their hospital discharge process in order to reduce readmissions. SHOW LESS READ MORE >

Executive Editor’s Note

Chapter 1: Overview
- Prevalence and Targets of Readmission Reduction Programs
- Readmission Reduction Strategies and Tools
- Program Content and Delivery
- Impact and ROI from Efforts to Reduce Readmissions
- What Happens at Hospital Discharge
- Barriers, Benefits and Results

Chapter 2: Case Management

Payoffs of Placing Case Managers at Primary Care Sites
- The Proven Health Navigator
- The Embedded Case Manager
- Selecting a Case Manager
- Case Manager Skill Sets and Key Qualities
- Case Manager Training and Support
- Identifying Target Populations for Case Management
- Post-Discharge Case Management
- Case Management in Home Health, SNFs and Care Transitions
- Success from the Case Manager Effort

Chapter 3: Care Transitions Management

Geisinger Uses Care Transitions to Enhance Care Co-ordination
- The Medical Home’s Role in Care Transitions
- Five Components of Geisinger’s Medical Home Approach
- Integrated Population Management Shows Providers Their Populations
- Case Managers: Keys to Success
- Patient Self-Management Action Plans
- Program Impact on Readmission Rates
- Moving from Pilot to Practice

Infrastructure and Incentives for Reducing Avoidable Hospital Admissions.
- Aetna APNs Tackle Transitional Care
- Promoting Successful Discharges and Handoffs
- Linking Transitional Care Effort with Case Management
- Improvements and Outcomes

Managing Medicare Transitions to Avoid Inpatient Admissions
- The Changing Role of Family Caregivers
- How and When Care Transition Breakdowns Occur
- The Challenge of Managing Senior Care
- Acute Problem Management
- Physician Relationship Management
- Utilization and Cost Outcomes

Chapter 4: Telephonic Monitoring

Readmission Avoidance: Lessons from Priority Health
- The IHI Triple Aim Model
- Pilot for Population with Cardiovascular Conditions
- In-Hospital Process Heads off Readmissions
- Outpatient Case Management
- Value of Follow-Up Visit
- The Post-Discharge ‘Handshake’
- Outcomes of Cardiovascular Initiative
- Expanding the Care Transitions Intervention
- A Priority Health Success Story
- Hope from the Patient-Centered Medical Home

Magnet Hospital Aims for Perfect Care of Heart Failure Patients
- Barriers to Effective Heart Failure Management
- Types of Heart Failure and Evolution of Treatments
- Inpatient Care, Outpatient Management Affect Outcomes
- Creating a Multidisciplinary Heart Failure Inpatient Unit
- Approach Includes Care Management and Home Care Team
- Seamless Care Means Patient Support and Telephonic Follow-up
- The Subacute Care Initiative
- Multidisciplinary Heart Failure Team
- Meeting Core and Quality Measures
- Medication Reconciliation
- Toward 100 Percent Identification of Heart Failure Patients

Chapter 5: Hospital Discharge Planning

Coordinated Discharge Planning to Reduce Readmissions
- Is ‘Discharge’ a Dirty Word in Healthcare?
- Reasons for Readmissions
- Teach-Back and AskMe3 Methods
- Closing Gaps in the Hospital Discharge Process
- Defining the High-Risk Patient
- Resources for Improving the Hospital Discharge
- Six Ways to Improve Communication with Patients at Discharge

CHOICES Program Breaks Down Barriers to Care
- CHOICES Takes Collaborative Approach
- Services Provided by CHOICES
- Significant Referral Sources
- CHOICES Program Outcomes

CASA: Discharge Planning via Community Collaboration
- The Importance of Community Collaboration
- Getting the Frail and Disabled Home
- Lessons Learned in Discharge Planning

Chapter 6: Medication Adherence, Reconciliation and Review

Medication Therapy Management
- Argument for Pharmacist-Led MTM
- Responsibilities of the Clinical Pharmacy Team
- Virtual Pharmacy Team Members
- Cardiac Care Program Results
- Safe Transitions Skilled Nursing Facility Program
- Safe Transitions Results and Challenges

Achieving Medication Adherence through an Integrated Care Team
- Provider-Patient Communications
- Polk County’s Team-Based Approach
- Clinical and Cost Improvements
- Impact on Medication Adherence

Chapter 7: Home Visits

Using Home Visits to Reduce Avoidable Rehospitalizations
- The Care Partners Model
- Assessing Program Effectiveness
- Target Populations for Home Visits
- Safety Considerations for Home Visits
- Results from Home Visit Pilot
- Lessons Learned from Home Visits

Chapter 8: Patient Education & Coaching

Integrating Health Coaching into a Health Management Effort
- Implementing Health Coaching Programs
- Results of Health Coaching in Managed Care
- Transition Coach Program
- Advanced Illness and Coordinated Care Program
- Combining Coaching and Pharmacy Outreach
- Options for Living Self-Management Programs
- Results of Living Self-Management Programs

Chapter 9: Provider Incentives

Maryland Pay for Performance Reduces Potentially Preventable Readmissions
- Causes of Potentially Preventable Readmissions
- Maryland’s Pay for Performance Methodology
- Identifying the Readmission Spike
- Top 15 Reasons for Potentially Preventable Readmissions
- Actual vs Expected Readmissions Based on Patient Mix
- Sizing the Incentive for Hospitals

Chapter 10: Q&A

About the Authors