The rise of value-based payment models has made hospital readmission reduction a top priority for providers, and strategies abound for how to tackle this often-thorny issue. Perhaps the most effective approach to take, then, is one that blends two of the most effective care-coordination methods, according to Hospitals & Health Networks Daily.
This strategy, which "is beginning to gain notable traction," uses both medical and non-medical staff to coordinate post-discharge care management for patients. Unlike more traditional approaches, this "high-intensity" team is led by both a nurse practitioner and a social worker, both of whom work closely with emergency department or hospital staff discharge planners, and later the patient's primary care physician, to execute a comprehensive care-coordination strategy, according to H&HN.
Because this type of care-coordination team includes a diverse group of caregivers, it is able to serve a wide array of functions that not only prevent the medical reasons for rehospitalization, but the harder-to-crack socioeconomic ones, the article says. This approach tackles the latter with a strong emphasis on educating patients about medication, exercise and diet regimens as well as the characteristics of their diseases, and it leverages community resources to connect patients with even broader support networks.
Previous research has found this type of transitional care particularly effective for patients with complex conditions, a population that's at especially high risk for readmission, FierceHealthcare has reported. Thus 26 states have introduced initiatives that address the problem of hospital "superusers" through a variety of community-based efforts such as helping diabetic patients with grocery shopping and arranging for patients to receive goods and services like bus tickets, driver's licenses or blankets.
A hybrid approach to care coordination can provide benefits to hospitals beyond just reducing readmissions, H&HN notes. Not only are such strategies well-suited to value-based payment models, but they help hospitals reduce patients' overall length of stay and contribute to hospitalists' job satisfaction and performance. "And, with that, everyone wins," the article concludes.
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