Focus on Details Leads to 60% Fewer Readmissions

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Jennifer VanWinkle By Jennifer VanWinkle 
Clinical Product Manager, Change Healthcare
Empty wheelchair leaving hospital

As home health nurses, therapists and aides know all too well, caring for patients after they leave the hospital can be incredibly complex. But a program focused on relatively simple things like medication management, nutrition choices and transportation reduced readmissions in a Maryland community by 60%.

After being assessed by a nurse practitioner at the University of Maryland St. Joseph Medical Center (UMSJMC), patients enrolled in the program were reassessed by a registered nurse at the home and assigned a community health worker (CHW).

Supporting patients with complex conditions

After 16 months, the program saw readmissions among participants drop by more than 60%, according to UMSJMC. The premise of the program was not to focus on readmissions, which Dr. Mohan Suntha, former UMSJMC president and CEO and current president and CEO of the University of Maryland Medical Center, says aren’t the problem. “[Readmissions] are a symptom. The real problem occurs when patients with complex medical issues and unmanaged psychological or social challenges don’t receive the support they need to maintain their health,” he said.

UMSJMC partnered with Maxim Healthcare Services for the program. Maxim’s CHWs are trained to mitigate barriers to care and act as a liaison to existing healthcare services. “We know it’s often the simple things—missed medication, poor nutrition choices or lack of reliable transportation—that can lead to big healthcare costs,” said Maxim CEO Bill Butz.

Based on the program’s initial success, UMSJMC is expanding the partnership and establishing a new CHW role that will be dedicated to providing community-based support to patients with complex behavior health challenges. “This partnership has allowed us to step beyond the role hospitals have traditionally played in a patient’s recovery to create a measurable positive impact on the health of the population we serve,” said Dr. Thomas Smyth, current president and CEO of UMSJMC.

Taking a cue from the UMSJMC/Maxim program, home health executives might ask:

  • Do our nurses have the training they need to address issues such as medication management?
  • Do our nurses have the support they need to address logistical issues such as food shopping and transportation to medical appointments?
  • How can our organization provide the services needed to help hospitals step out of their traditional patient-recovery role?
  • How might our organization incorporate the community health worker role into our business model?

Readmission penalties still hitting hospitals

Readmissions continue to be an issue for hospitals. Analysis by Kaiser Health News shows that half of all U.S. hospitals are being hit with Medicare readmission penalties during FY 2017. According to the Kaiser analysis, the penalties affect about the same number of hospitals as in FY2016, but the dollar amount of the penalties is increasing by about 20%, or more than $500 million. The Kaiser analysis indicates that the penalties don’t affect just those six conditions covered under the regulations, but all Medicare recipients, making this a continuing front-burner issue for health systems.

Home health is situated squarely at the intersection of acute care and post-acute care. Regardless of geography, your organization serves patients that have been discharged from hospitals and rehabilitation centers. Your team is uniquely situated to care for patients where nearly all of them want to be—at home.

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