Care coordination initiatives – whether they’re paper-based or digital – have the potential to significantly reduce the nation’s healthcare bill.
One-in-five senior citizens discharged from the hospital is readmitted within 30 days, according to Qualidigm, a healthcare consulting firm. Many of these readmissions result from preventable complications and mismanagement.
[See also: Hospitals implement programs to boost care coordination]
To address these issues, several healthcare stakeholders are now putting care coordination programs in place to help patients transition from one care setting to another. In practical terms, that means making sure they receive all the necessary instructions when they are discharged, keeping their primary care physicians in the loop and helping patients during the transition from hospital to community life through a variety of social services.
Using several evidence-based quality improvement strategies to help Medicare patients make such transitions, healthcare providers have managed to lower 30-day readmission rates and all-cause hospitalization in two years, according to a recent study published in the Journal of the American Medical Association.
Participants in the government-supported programs “pumped up” the care coordination process in several ways. They coached patients to make them more actively involved in their own care; put in place a series of improvements in home care; and used a tool kit called INTEACT to help manage the status of nursing home residents and improve medication compliance.
Among patients enrolled in these experimental programs, readmissions declined by 5.7 percent, compared to 2 percent in comparison communities that did take advantage of these care coordination resources. The study researchers estimated that in a community of 50,000 Medicare beneficiaries, Medicare could save $4 million annually on readmissions for every $1 million spent on these community interventions.
Given the demonstrated savings of using care coordination tools, many hospitals and health systems are turning to a variety of plans incorporating such tools to help reach cost-saving goals.
The Johns Hopkins Health System is creating a robust call center to reach out “to every patient who is discharged from Hopkins, and update their documentation, in Epic, for all aspects of their experience that are relevant to their long-term care,” said Johns Hopkins’ CIO Stephanie Reel.
Reel said that the goal of the health system is “to provide comprehensive documentation, and meaningful information, at one place, in the patients’ completely electronic record, so that all members of the team, past, present and future can see it.”
Care coordination tools reduce the likelihood that patients will slip through the cracks in the healthcare system, said Jacob Nguyen, executive vice president of HealthBI, the maker of a care coordination software package called HealthCollaborate.
All care coordination tools, if used properly, he said, can create the vital links between healthcare facilities that don’t always communicate as well as they should – among themselves and with their patients.