Reducing Patient Readmissions with Data and Communication Technology

Speaking with One Voice Matters When It Comes to Patient Care

Reducing patient readmissions is a top priority for most health systems. A hospital readmissions reduction program will benefit from leveraging a unified clinical communication and collaboration platform to align care teams and keep patients on track with their care plan and recovery. 

Nearly half of U.S. hospitals will receive lower payments in 2021 for all medicare patients because of their readmission rates – an added financial burden as hospitals continue to feel the impact of the pandemic. But as Jefferson Health (formerly Kennedy Health) discovered, the solution may already be within arm’s reach – in their patient data. 

By leveraging the tools of an integrated, clinical communication platform, Jefferson Health drastically reduced emergency department (ED) overutilization, hospital readmissions, and wasted care. 

Jefferson Health – A Case Study on Reducing Patient Readmissions 

In 2013, Jefferson Health (JHNJ) discovered that just 21 “super-utilizer” patients accounted for 903 visits to its emergency departments in one six-month period. After implementing TigerConnect, JHNJ integrated their electronic health record (EHR) system to trigger automatic alerts when a “super-utilizer” patient checked into any of their emergency departments across three campuses. Nurse navigators were then able to intervene to determine if readmission was necessary or if a simple medication adjustment or referral for outpatient care would better serve the patient.

By implementing The TigerConnect Solution, Jefferson Health has seen a 73% reduction in ED utilization among this targeted population, a 22% decrease in Congestive Heart Failure (CHF) readmissions, and a reduction of unnecessary tests and medications resulting in increased staffing resources.

“When we started using this tool — and really tracking these patients — we were able to see that with these real-time interventions beginning in the waiting room, we were able to decrease the number of times these patients were presenting to the emergency room by at least 70 percent.” – Maryann Lauletta, M.D., vice president of medical operations, Jefferson Health.

 

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Benefits of Using Collaborative Communication Tools

A unified clinical communication and collaboration platform helps health systems connect care teams so that everyone involved in a patient’s care is updated and current on all treatments and recommendations. Below are some of the benefits of integrating with a Clinical Communication & Collaboration (CC&C) solution like TigerConnect.

• Streamlined communication and faster clinical decisions. The TigerConnect Clinical Collaboration Platform replaces fragmented messaging from pagers, phone calls, and EHR inbox messages with a HIPPA-Compliant solution for streamlined communication directly to your smartphone. Most text messages are read in less than 10 seconds, which shows that texting improves response time over legacy communication modes like paging and voice messaging. 
• Improved care team collaboration. Securely collaborate with the entire care team (physicians, nurses, PTs, care managers, pharmacists, outside providers, etc.) through a centralized platform, keeping everyone updated and current on medical history, labs, PACs, and recommendations. This level of collaboration paves the way for a coordinated care plan. 
• Efficient handoff coordination and reduced hospital readmissions. EHR-agnostic handoff coordination tools support direct collaboration between providers so that the entire care team can see who is responsible for overseeing the patient’s next steps. This also supports more explicit post-discharge instructions, reducing the likelihood the patient will end up back in the emergency department.
• Higher patient satisfaction. When care teams can communicate, collaborate, and make care decisions more efficiently, they can spend more time focused on the quality of care each patient receives. 

Strategies for Bringing Readmission Rates Down

A unified clinical communication platform is the most effective and efficient way to speak to a patient with one voice and keep them on track for care plan adherence and recovery. Here are 3 strategies to keep in mind as you address your organization’s readmission rates:

Automate processes to support early intervention 

One of the keys to Jefferson Health’s success was intervening before patients were admitted to the hospital through the use of automated alerts. A readmission alert system can notify key providers and care managers when returning patients present in the ED. In the case of Jefferson Health, nurse navigators were able to coordinate with the patient’s care team and arrange medication adjustments or more suitable outpatient care right from their smartphone.  

Dig into patient data

Do you have a high percentage of super-utilizers? Super-utilizers place a noted burden on hospitals across the U.S. However, interventions through community navigators can reduce readmission rates and potentially save costs. By setting up automated alerts for super-utilizers and stationing a nurse navigator in their emergency department, Jefferson Health reduced readmissions for this group by 73%.

Streamline collaboration with one platform

Communication interventions are associated with lower readmission rates, higher medication adherence, and higher overall patient satisfaction. When the entire care team, including those outside the hospital network, can collaborate on a single platform, patient follow-up care is less likely to fall through the cracks. 

Images and test results can be exchanged between providers, primary care physicians can coordinate discharge instructions with the on-call hospitalist, and nurse navigators can access the complete care plan and coordinate after-care assistance. The patient has a better chance of adhering to their responsibilities in managing their care when the instructions are clear.

Additionally, communication interventions that support direct communication with the patient increase the likelihood of care plan adherence. Automated reminders sent to high-risk patients to take medications and check their weight or blood sugar can keep patients on track. Patient engagement is also enhanced through bi-directional texting between the patient and care coordinator. Care coordinators can reach and impact more patients through texting due to the rapid response rate of texts. Given the answer rate for phone calls is notoriously low, giving staff additional tools to reach patients helps improve outcomes and efficiency.

The TigerConnect Collaboration Platform supports efficient, collaborative, and patient-centered hospital environments where reduced hospital readmissions are a common outcome. If you’d like to learn more about how integrating with a clinical communication and collaboration platform can support your team and improve the lives of your patients, contact TigerConnect today.

1. Medicare Fines Half of Hospitals for Readmitting Too Many Patients [Internet]. Kaiser Health News. 2020 Nov. 2. Available from: https://khn.org/news/medicare-fines-half-of-hospitals-for-readmitting-too-many-patients/
2. Michael P. Thompson, Pradeep S.B. Podila, et al. Community Navigators Reduce Hospital Utilization in Super-Utilizers. The American Journal of Managed Care. 2018 Feb 15. Available from: https://www.ajmc.com/view/community-navigators-reduce-hospital-utilization-in-superutilizers
3. Christoph Becker, MD; Samuel Zumbrunn, BMed; Katharina Beck, Ph.D., et al. Interventions to Improve Communication at Hospital Discharge and Rates of Readmission. JAMA Network Open. August 27, 2021, doi:10.1001/jamanetworkopen.2021.19346

Tags: readmission rates, patient readmissions, Clinical Collaboration Platform, hospital readmissions