Solutions Guide: Reducing readmissions with analytics

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 ajicjournal.org.
Source: Association for Professionals in Infection Control and Epidemiology (APIC)

Books and Literature

Pop health’s good read

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