Reducing Hospital Readmissions Through Care Guidance 

A key measure of healthcare quality in value-based care is a hospital’s readmission rate, or the percentage of patients who experience unplanned readmission post-discharge. Readmissions disrupt the patient journey, erode the quality-of-care delivery, lower patient experience and satisfaction, and drive a significant proportion of associated expenditures. Readmissions following inpatient discharge are estimated to cost Medicare $26 billion annually, with $17 billion of that amount attributed to preventable readmissions after discharge. 

From the provider perspective, hospital readmissions consume clinical resources and become burdensome for clinical staff, straining their capacity to intake and care for new patients. Beyond the financial penalties imposed by CMS in the Hospital Readmission Reduction Program (HRRP), Medicare Advantage plans and commercial payers are increasing denying claims for readmissions they consider avoidable, and some MA plans have adopted penalty programs similar to HRRP for providers who they deem to have excessive readmissions.

Root Cause: Non-Clinical Social Factors

Research and published results show that risk for readmission is high among patients facing health inequities and disparities – the preventable differences in the burden of disease or opportunities to achieve optimal health. According to CMS, minority and socially disadvantaged populations are more vulnerable to be readmitted within 30 days of discharge for chronic conditions. 

Other studies have shown that certain patient populations are at higher risk for hospital readmission. Research in the Journal for Healthcare Quality found socioeconomic factors, such as race, income, and payer status, are correlated with rehospitalization rates, and patients with certain conditions also have higher rates of readmission. To identify those most at-risk requires consideration of the full spectrum of a patient’s health as well as their socioeconomic conditions. Social determinants of health (SDOH) impact a patient’s ability to access, receive and adhere to care. Issues that manifest by these non-clinical factors, if not addressed and promptly resolved, can lead to health deterioration, costly readmissions and extended hospitalizations. 

While not all readmissions are avoidable, a portion can be anticipated and prevented pre-and-post-discharge and along the continuum of care. Transitional care  and other forms for post-discharge follow-up have been shown to significantly decrease hospital readmissions. At-risk patients require amplified levels of activation and monitoring that cannot be addressed with the typical hospital’s resource capacity and clinical scope limitations. 

The complexities of the discharge process, understanding instructions, scheduling follow-up appointments and adhering to treatment plans and medication compliance highlight the importance of connected care, provider engagement and patient activation. Of course, CMS has worked to recognize these complexities by taking these non-clinical factors into account in Risk Adjustment Factor scoring, among other initiatives. The Joint Commission has also made addressing these human factors a key measuring point for providers.

Care Guidance Solution

To reduce readmissions, innovative health systems are implementing structured care guidance programs that work to identify, understand and resolve non-clinical issues that hinder a patient’s adherence and compliance before these issues become problematic and costly. 

Care Guidance, also referred to as “care navigation,” coordinates and facilitated the post-discharge transition and continuation of care between a hospital and multiple healthcare providers. An ongoing relationship is established to proactively support and guide a patient through their healthcare continuum. The primary goal is to ensure that the patient receives the right care at the right time, in the right place with the right outcome. 

For the hospital, care guidance extends non-clinical support to improve their provider’s ability to render patient-centered and value-based care in the context of the Triple Aim of improving patient experience, advancing population health and reducing total cost of care. 

How Care Guidance Works

Success of a care guidance program rests largely upon the shoulders of specially selected and tech-enabled “care guides” who work to establish a peer-to-patient connection with patients and their families. This human-led approach builds trust, lowers a patient’s resistance to sharing information and helps to uncover potential barriers they encounter. 

During the administration of screenings to identify health-related social needs, care guides conduct routine symptom assessments that can identify potential indicators of clinical deterioration earlier in the disease trajectory. Optimally, care guides are equipped with scalable, technology platforms that provide structured workflows and use evidence-based disease and condition-specific protocols to proactively identify (and resolve) non-clinical barriers while also using standard symptom assessments. Through this level of support, care guides ensure that clinical issues are immediately escalated to proper clinical care teams. 

Data Captures SDoH Insights

An effective care guidance program captures SDoH data and disparity-related barrier resolution for operational improvement. This data can supplement the capabilities of electronic medical records (EHR) systems.AI and machine learning can be applied to anticipate patient needs based upon condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communication. Led by this intelligence, care guides provide patients with the information they need to engage in the process of their care and empower each patient to receive a better understanding of their treatment plan and compliance options.

A Strategic and Compliant Approach to HRRP and HCAHPS

Care guidance can be strategically implemented to improve care coordination, enhance patient engagement and experience and reduce unnecessary readmissions to improve performance under the Hospital Readmissions Reduction Program (HRRP). 

• Supports ‘high-value, high-quality care’ required to meet incentivized goals
• Advances heath equity priorities of quality programs and payment models
• Improves the provider’s ability to negotiate favorable contracts with payers
• Optimizes financial and operational performance in managed care

For providers seeking to improve their performance in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) assessments, care guidance can offer a comprehensive solution by using targeted, telephonic care guidance using disease specific outreach designed to identify and address factors that could potentially lead to poor satisfaction, adverse outcomes and readmissions in the general post-discharge patient population.

• Conducts post-discharge surveys including HCAHPS 
• Confirms patients understand discharge instructions
• Ensures any post-discharge appointments are correctly scheduled
• Identifies and resolve non-clinical issues and barriers that impede adherence
• Complies with CHSLI guidelines for clinical escalation, when appropriate

Supplementing National Nursing Shortage

One key to lowering readmission rates is to ensure that health systems have appropriate nurse staffing levels. Studies have found a clear correlation between the number of nursing staff at a hospital and its 30-day readmission rates—one 10-year study found a higher number of RNs was associated with lower readmission rates of approximately 8%, according to ScienceDirect.

More healthcare systems are experiencing the profound financial impact of nurse shortages. 

McKinsey advises that worsening clinical labor shortage will contribute to projected increases in healthcare costs over the next five years. Nurses engaged in patient navigation and care coordination report that a significant amount their workload is burdened by addressing non-clinical patient issues and practical tasks, like scheduling follow-up visits, ensuring transportation and attending to a myriad of issues and barriers to care attributed to SDoH. Anywhere from 10-20% of patient issues are being recorded as clinical, physical barriers while the other 70-80% come from practical, non-clinical barriers.

The American Organization for Nursing Leadership’s 2022 Nursing Leadership Workforce Compendium of workplace best practices recommends, among other things, looking for opportunities to offload time-consuming tasks for nurse leaders. Offloading these time-consuming tasks with internally built solutions is itself time- and resource-intensive. Partnering with a company that specializes in non-clinical work with purpose-built technology and structured workflows is an ideal way to relieve non-clinical tasks in order to mitigate clinical staff shortages, maximize the efficiency of nursing teams, and alleviate strains on hospital workflows and resource capacity.

Conclusion

Care guidance is rapidly becoming an essential addition to the service portfolio of health systems, hospitals, and provider organizations. It is at the nexus of this change where care guidance represents an innovative approach to patient activation that is delivering “high-value, high-quality care.”

The addition of a care guidance program beyond legacy navigation efforts provides organizations with truly effective support services, functioning as a lower cost extension of clinical teams and freeing up labor, time and resources so that clinicians can focus on high-value clinical tasks. The value of human interaction and the profound impact of personalized care guidance is evident in reducing unnecessary utilization and readmissions, as well as advancing health equity, improving patient experience and meeting goals of value-based care.