The Best Way to Reduce Hospital Readmissions for Chronic Patients

We all know that hospital readmissions are bad for the healthcare system. They negatively impact government budgets and strain facility resources. Worse, they decrease quality of life for the patients involved.

Unfortunately, readmissions are all too common. According to a recent study, 1 in 12 Canadian patients is readmitted to the hospital within 30 days of being discharged.

Those with chronic conditions are often at higher risk. This is bad news, given that rates of chronic disease are on the rise.

The good news is, there are steps healthcare professionals can take to keep chronic patients out of the hospital. It starts at the top, with a commitment to better discharge planning and follow-up care.

In this post, we’ll look at the growing burden of hospital readmissions due to chronic disease. we’ll also explore potential solutions.

A Problem That Can’t Be Ignored

As our population ages, the number of people with diseases such as diabetes, cancer, and chronic obstructive pulmonary disease (COPD) is growing. More and more, doctors are seeing patients who have several chronic diseases.

The complexity of these conditions is creating new challenges. In some ways, care providers aren’t equipped to deal with them.

After a hospitalization, a patient can expect to continue dealing with her chronic conditions. She may face some difficulties while trying to navigate the healthcare system. What she shouldn’t have to deal with is an unplanned readmission.

And yet, readmission is no small concern for chronic patients.

Research from Brigham and Women’s Hospital has found that the most frequent reason for readmission is often related (directly or indirectly) to underlying chronic conditions.

For provincial and federal governments, the costs are significant. A Canadian Institute for Health Information study found that, over an eleven-month period, unplanned readmissions cost the healthcare system $1.8 billion.

For hospitals, dealing with adverse events more than once means expending precious resources.

According to some critics, readmissions often occur because of a rush to discharge patients. But most hospital executives know that sending patients home too soon is costly in the long run. Few would argue that this is a sustainable way to operate.

Unfortunately, the demand for services is mounting. So too are the difficulties associated with transitioning patients from hospital to home. If you’re a healthcare leader, you need to think critically about new ways of delivering care.

Planning & Follow up: the Keys to Reducing Hospital Readmissions

For patients, navigating the healthcare system can be tricky. But as models of care evolve, many hospitals and service providers are dealing with confusion, too.

In home settings, there are more opportunities for communication between providers to become fractured. The consequences can be especially bad for patients with chronic diseases, which require ongoing management.

Too often, gaps in care occur. Hospital readmissions frequently follow. This is why discharge planning is so critical. Coordinating care and clarifying areas of responsibility have never been more important than they are now.

Of course, there’s no one-size-fits-all solution. When it comes to discharge planning, patient goals and preference should play a central role. But practical, day-to-day details are just as critical.

Let’s say a patient is leaving the hospital. What, exactly, should happen now? When will her next contact with the healthcare system occur? What’s the first lifestyle change she needs to implement?

Note the patient’s state of mind when she’s absorbing this information. Is she likely to remember self-care instructions? If not, she may wind up back in a hospital bed a few days after discharge.

Consider the importance of careful coordination. As the Ontario Medical Association notes, poor communication during transitions can increase the incidents of hospital readmissions. On the flip side, excellent communication can help prevent them.

Consider a typical care plan created at your facility. Does it encourage collaboration? Is it easily accessible to everyone within the circle of care of the patient in question?

Do care providers and coordinators have an easy way of sharing time-sensitive information?

Has a follow up schedule been hashed out? Is it sufficient for assessing the patient’s plan adherence, progress, and general wellbeing?

Has family involvement been considered? Does the plan make the most of personal support systems?

These are just a few important communication questions to ask.

Innovative Approaches

Understanding the challenges of reducing hospital readmissions is one thing. Implementing solutions that work is another. The issue identified above raise a whole new series of questions.

The risk of readmission should be assessed during discharge planning. But how?

Follow-up visits should be planned to meet patient needs. But what if there aren’t enough resources to make this happen?

Care providers should be able to consult with one another in real time. But what if phone calls don’t provide enough information?

Luckily, innovation is solving some of these problems. Healthcare executives have reason to be optimistic.

First, there are new service delivery models. For all of its benefits, home care can lead to fractured communication between providers and patients. But provincial initiatives are changing that.

For example: Ontario’s Health Links were designed to connect care providers. The idea is to make it easier for patients – especially those with chronic and complex conditions – to navigate the system. There’s a lesson here for health executives. Improving infrastructure for those who use services lays down a solid foundation for better care.

Technological innovation provides the tools to help practitioners create that higher level of care.

When it comes to risk assessment, LACE – a tool developed by Canadian experts to predict unplanned readmissions – is very promising.

For preventing readmissions, strengthening circles of care and the flow of patient information within them is critical. In addition to better care planning, tools that improve communication are key.

Videoconferencing platforms offer comprehensive solutions. The benefits of using these tools for follow-up care are clear. They make it easy for doctors, nurses, and other practitioners to check in with patients – without using up valuable time to travel.

Video can also greatly improve coordination between a patient’s care providers. It’s not just about instantaneous patient updates related to medication, symptom distress, and other factors. It’s about real-time consultations between experts and caregivers.

Chronic wounds, for example, can cause multiple hospital readmissions. What happens when a wound care expert coaches a home care nurse to provide treatment through high-quality video? The result may just be one less chronic patient in a hospital bed.

Of course, not all solutions are created equal. Service providers should look closely at communication tools. And remember the benefits of improving care coordination on an ongoing basis. From the moment a chronic patient is discharged, connecting his circle of care can reduce his chances of being readmitted.

The Bottom Line

Hospital readmissions pose a serious threat to the Canadian healthcare system. The number of patients with chronic diseases is on the rise, which means these events are set to become even more common.

But healthcare providers can counteract this trend. Improving discharge planning and follow up through better coordination is key. One of the best ways to do this is by advancing communication within circles of care. Being open delivery models and tools that support this goal will serve healthcare leaders well in the years ahead.

Feature image courtesy of lee

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