What are the best ways to predict and prevent readmissions in value-based programs?

By Michael Corbett, AVP

The priority to succeed in value-based programs is not new but with continued advancements in approaches, moving the needle year over year, is becoming increasingly difficult.  Continually moving the needle in the management and prevention of readmissions, it one of these examples. In order for health systems to sustain their performance and be seen as a top-tier system, a systematic, structured approach much be in place.  An outline of key approaches to succeed in this area is below:

  1. Understand and study your current performance and population. Simply put, from data analysis, understand the commonalities and themes that are driving readmissions. For example, what diagnosis’ have a higher change of readmission? How does polypharmacy impact risk of readmission? Do any socio-economic demographics incline someone for a readmission, i.e. zip code? 
  2. Establish performance scorecards for your community partners and discuss opportunities on a consistent basis.  In order to achieve long term success in readmission prevention, it is a necessity to be aligned with your community partners.  This isn’t system alignment, but alignment of outcomes and understanding of mutual benefit.  Through measurement of your community partners and regular discussions/meetings on their performance, great gains can be made to improve gaps in transitions of care. Through understanding of these gaps, enhanced processes can be built to smooth transitions, identify care pathways that need to be solidified and responsibilities of parties involved to prevent reoccurring issues moving forward.
  3. Utilize IT and EMRs to help your team be more focused and efficient.  Whether you utilize a robust tool to measure risk in a more real time manner or have single alerts built into your system to ping when an individual presents with a certain diagnosis, take the time to build a system that supports proactive identification of a potential readmission.  It does take time for a team to build a process that works, but it doesn’t have to be perfect.  Don’t sacrifice improvement gains under the concept of having a perfect process in place.  The key is to allow our IT systems to support our work and allow us to be more targeted in our interventions.
  4. Communicate, Communicate, Communicate. I know, this should be standard, but its often the step that causes most slip ups or failures.  Continual improvement takes commitment, focus and time.  Lots of individuals are involved and it is top priority to ensure all team members are kept up to date on performance and how the work they are doing is impacting results.  If information is not consistently communicated, team members lose focus and question the necessity of key steps quickly.  Take the time to establish key performance dashboard and communication pathways to maintain constant flow of information to all parties involved.

Its key to remember a one-size fits all approach doesn’t work for your system because it worked at another, however, from experience with working with many institutions, the key principles above are common threads seen amongst many.

Michael Corbett, AVP, Clinical and Operational Improvement at Quorum Health Resources, a healthcare professional services consulting company for non-urban hospitals and health systems: Michael has performed system case management redesigns, patient flow implementations that reduced LOS and saved millions of dollars year-over-year at several health systems. He ensures in each of his projects the team understands the impact improved processes brings to the hospital revenue cycle and bottom line. He works closely with leadership to understand and reduce variances in process to reduce costs and create long-term sustainable change.