Solutions Guide: Reducing readmissions with analytics

June 25, 2015
Population Health
Customizing care
By Alan Bugos, Head of Technology and Innovation, Philips Home Monitoring

Analytics has the power to help solve the readmission challenge by providing a deeper level of insight into the patient’s health journey. As key to population health management, analytics can provide critical insights into entire patient populations, going as micro as identifying individual patients who are at risk for adverse medical events and as macro as identifying gaps in care for whole populations.

One of the key benefits of analytics is its power to provide health systems and clinicians with the ability to identify who is at risk and preemptively intervene before an adverse medical or life-critical event occurs, helping provide better quality care for patients and reducing unnecessary hospital admissions and readmissions. By utilizing analytic-driven population health management solutions, clinicians get the knowledge they need to customize care delivery, creating a clearer path in today’s complex healthcare environment and yielding a more significant impact on patient health.

For patient care to be impactful, it needs to be connected across the health continuum. This extends past the traditional 30-day window considered for readmissions and requires looking at the larger story of a patient’s health. Most healthcare systems agree that reducing readmissions is a win-win scenario for improving care and reducing costs, but regulations have caused many to focus only on the 30-day post-discharge period. Under the shift to value-based care and population health management, this mindset will need to change, especially when dealing with patients who have chronic conditions that cause frequent, preventable hospitalizations.

One patient population this is especially important for is seniors. Seniors are the largest consumers of healthcare, but poor transitions in care are a key cause for readmissions, emergency department visits, and unnecessary hospitalizations. By looking at the full picture across the full health continuum and using data and analytics to monitor seniors’ health while they are at home, healthcare systems can identify the patients most likely to have health issues, allowing clinicians to intervene before problems occur – and helping seniors stay healthier and out of the hospital.

In a world of mobility, it becomes easier to collect data, and the variety of data we can gather expands broadly as healthcare technology evolves. Going hand in hand with evolving analytic capabilities, wearables, health apps, and telehealth programs are using advanced technology to take steps toward better physician/patient connectedness, opening the door for real-time insights that are actionable. By creating more data touch points to analyze, clinicians not only get a more comprehensive patient profile, but they can better customize patient care and identify potential solutions.

Telehealth solutions extend patient care from the hospital and into their homes, ultimately improving care, cutting costs, and reducing hospitalizations. They provide innovative clinical programs that allow health systems to improve health and lower the cost of select patient groups in all care settings, both inside and outside the hospital. A health system supported by a mix of advanced telehealth technologies and analytics-driven population health management solutions has the power to truly impact not only readmissions, but also patients’ overall health.

Research and Studies
Twice as likely to readmit

A recent study of Clostridium difficile (CDI or C. diff) infections published in the April 2015 issue of the American Journal of Infection Control revealed that patients diagnosed with the deadly diarrheal infection (whether in the community or acquired during a hospital stay) are twice as likely to be readmitted to the hospital within 30 days.

Researchers from the Detroit Medical Center (DMC), a seven-hospital system in southeastern Michigan, conducted the large study to understand the epidemiology of CDI readmissions, analyzing 51,353 all-cause discharges between Jan. 1 and Dec. 31, 2012. There were 615 patients (1 percent) who were discharged with a CDI diagnosis, including 318 where CDI was present on admission, and 297 who were diagnosed during their hospital stay. The study indicated that 30.1 percent of CDI patients were readmitted after 30 days versus 14.4 percent of all-cause discharges.

“We found that CDI readmissions for any reason had almost a one-week longer average length of stay than all-cause readmissions,” said Teena Chopra, M.D., MPH, a leading CDI expert from DMC’s Division of Infectious Diseases who led the study.

According to the CDC, C. diff has become the most common microbial cause of healthcare-associated infections in U.S. hospitals, costing up to $4.8 billion each year in excess healthcare costs for acute care facilities alone. Patients who take antibiotics are most at risk for developing C. diff. Learn more about this study in the article, “Burden of Clostridium difficile infection on hospital readmissions and its potential impact under the Hospital Readmission Reduction Program” at
Source: Association for Professionals in Infection Control and Epidemiology (APIC)

Books and Literature
Pop health’s good read
If you need help navigating the uncharted waters of value-based care and how population health outreach can contribute to provider reimbursements for healthy outcomes, you are not alone. Luckily, a new book aims to set physicians and health administrators on course.

“Provider-Led Population Health Management” by Richard Hodach, M.D., and Phytel’s Chief Medical Officer and Vice President of Clinical Product Strategy, aims to explain how providers can lead population health management (PHM) initiatives using automation to fit the effort within care teams.

“This book connects the dots for physicians embracing population health,” says David B. Nash, M.D., MBA, founding Dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, the nation’s only school of population health. “It takes components of population health management, such as ACOs, PCMHs, and shared savings contracts, and clearly articulates expert definitions.”

Included in the primer is information on how organizations can use health IT to automate care management and patient engagement in order to scale and prioritize care delivery to the level required to achieve PHM. The 266-page paperback is available on Amazon. Source: Phytel

Master coordinated care transitions
With its fully integrated EHR, MEDITECH supports coordinated care transitions that help healthcare organizations eliminate unnecessary readmissions and maintain their bottom lines. Several key system features give providers the tools they need to see a complete clinical picture of their patients – inside the hospital as well as outside of it – and provide a multidisciplinary approach to care management and discharge planning. These include: customizable surveillance status/quality boards, comprehensive medication reconciliation, integrated home care solution (including a telehealth option), and a Web-based patient and consumer health portal for better patient engagement. MEDITECH
Home monitoring data connected to EHR
Cerner, through a partnership with Qualcomm, is extending its medical device connectivity capabilities beyond the hospital and into the home. Cerner will leverage Qualcomm Life’s FDA-listed 2net Platform and Hub to capture data from medical devices and sensors (such as weight scales, blood pressure
monitors, and pulse oximeters) within a patient’s residence and transmit it to Cerner healthcare clients through Cerner’s CareAware device connectivity platform. Using this solution, care providers can remotely monitor chronically ill patients in near real time to enable proactive engagement and potentially reduce the risk of an acute care episode. Data values will transmit via CareAware to the Cerner Millennium EHR and be viewable to the patient in HealtheLife, Cerner’s patient engagement solution. Cerner
Data + devices = better analytics for care
CareSage combines actionable insights with wearable medical alert devices to help reduce avoidable hospitalizations of elderly patients, keeping them at home and independent. This predictive analytics engine provides analysis of real-time and historical data from healthcare providers and Philips Lifeline to proactively identify patients most likely to have health issues so clinicians can intervene before problems occur, helping patients stay healthier and reduce avoidable hospitalizations. CareSage is the latest innovation being built on the Philips HealthSuite Digital Platform, an open cloud-based platform that supports the secure collection and analysis of health and lifestyle data from multiple sources and devices.Royal Philips
Research and Studies
What an extra day can bring

Ever wondered if staying in the hospital an extra day can really do any good? Researchers at the Columbia Business School have, and they say that keeping patients in the hospital just 24 hours longer can significantly cut readmissions, save patient lives, and reduce costs.

Their study, “Should Hospitals Keep Their Patients Longer? The Role of Inpatient and Outpatient Care in Reducing Readmissions,” compares the impact of an extended length of stay in the hospital to the effects of outpatient care for Medicare patients. In it, the researchers found that one additional day in the hospital can:

  • Reduce mortality risk by 22 percent for patients treated for pneumonia;
  • Reduce mortality risk by 7 percent for heart-attack patients;
  • Result in five to six times more lives being saved when compared with outpatient care; and
  • Decrease readmission rates by 7 percent for severe heart-failure patients.

Additionally, the study showed that one extra day in the hospital would, in many cases, cost less overall than the associated outpatient care required with early discharge. Currently, about one in every five Medicare patients is readmitted to the hospital within 30 days of discharge, costing U.S. taxpayers at least $17 billion annually.

The study analyzed the Centers for Medicare & Medicaid medical records of more than 6.6 million Medicare patients ages 65 or older with in-hospital visits between 2008 and 2011. It compared the potential benefits of a one-day extended hospital stay to those of outpatient care in terms of reduced readmissions, death rates, and costs. Study results were released in October 2014.

Read more about this study at

Reach out and learn about someone
The new Caradigm Patient Outreach solution leverages Eliza’s expertise in crafting highly effective, multi-channel patient interactions to enable providers and ACOs to reach outside the care setting and engage patients in health-related behavior change. Interactions are targeted based on patients’ clinical and life circumstances, making the messaging more relevant and compelling, and leading to improved patient involvement. The system also gains insights about patients based on each interaction, resulting in improvements in both the effectiveness of interactions and patient perceptions of their provider organizations. This solution specifically targets onboarding, health risk assessment, transitions of care, and gaps in care. Caradigm

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