Managing, reducing patient rebounds starts with data

You may have noticed a consistent theme in the move toward fee-for-value models—the need for timely, relevant data. As with any part of the healthcare continuum, reducing patient readmissions and ER rebounding takes timely, relevant information with which leaders can develop and modify programs.

Care transition success is no different. Hospital leadership and care managers need interactive dashboards to quickly review outcomes that allow for immediate action, when necessary. Such dashboards should highlight performance on an aggregate level, then segment the information around key attributes that include market, payer, product, facility and diagnosis.

The end goal is to find anomalies in rebound and readmission rates that foster better understanding of how to treat particular populations or individual patients. To do this, organizations must collect and analyze metrics beyond the overall 30-day readmission and 30-day ER return rates. We recommend tracking and analyzing the following data:

  • Payer/product: Tracking all 30-day readmissions by payer and product type—not just Medicare readmissions—will position hospitals for greater accountability. Organizations should track and analyze fee-for-value contracts as well as traditional PPO, HMO, and fee-for-service contracts.
  • Diagnosis: Organizations can find overarching issues with the care of certain types of conditions.
  • Timeframe: Using a baseline of rebounded patients, cross-referencing patients by the timeframe within which they are readmitted can help care managers determine the reasons behind the rebounding.
  • Discharge place-of-service: Seeing where readmissions and ER returns occur allow organizations to see where to target care transition programs.
  • Length-of-stay: It’s vital to measure how many days a rebounding patient stays in the facility. A one day length-of-stay likely means the previous discharge was too early; a longer stay could be due to a hospital-acquired infection or other factors.
  • Service type: Not all admissions are equal, nor are rebounds. Surgical readmissions could signal a hospital-acquired infection that demands study of surgical protocols. Medical readmissions could be due to chronically ill patients who are not managed properly.
  • Physician: Track this information to find outliers among primary care providers of discharged patient.
  • Post-follow-up visit rate: Knowing if patients are following up with their providers in a prescribed timeframe allows an organization to monitor and enhance processes to ensure patient adherence.

Data can point to problems, and is the starting point to finding solutions to readmission and rebounding issues. But it is only when root causes are known should organizations develop and implement programmatic interventions.

To read more about in-home outreach programs, download the white paper:  “Preventing Patient Rebounds: Value-based Care Organizations Should Focus on More Than Just Readmissions.”

Miles Snowden, MD, Chief Medical Officer, Optum

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