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High Risk Readmission Prevention - Becoming Proactive


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    According to a recent publication in the Remington Report, Medicare is reducing payments to 2,499 hospitals and 47% of SNF, nationwide, due to readmissions to the hospital.  Timely management of care transitions are a priority to improve quality and patient satisfaction, while reducing readmissions and healthcare costs for population health.

    Readmissions after SNF discharge, following a heart failure hospitalization is currently the highest in the first two days of the patient returning home.

    Initiating engagement of patients with post-acute providers during the first day of their hospitalization will begin to make the difference. Aligning patients, their families, the hospital, and physicians toward the goal of discharge to the right setting without unnecessary delays is key to a better experience, while beginning to lower costs. 

    Discharge destination decisions are reactive, based on the availability of beds or subject to referral patterns that may not be grounded in value or measurable outcomes. Overcoming this requires established relationships with a network of high-quality post-acute providers in the community. 

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    In 2021, APEX Palliative Pathways provided service to 219 patients, referred through the Silver Cross Hospital systems.  Together, in a six-month period, those 219 patients had 427 hospitalizations, meaning repeat readmissions.  Of those 219 patients, while receiving Palliative services, hospitalizations decreased by 90%, with only 40 hospitalizations.  

    Palliative and Transitional Care provides the opportunity to see patients in their own environment and capturing those triggers which would normally result in readmission to the hospital.  Triggers such as not understanding medication dosage and administration, safety measures in the home, the need for emotional, psychosocial, or spiritual support, improper nutrition, etc. the list can be endless.

    When the hospital, SNF or physician office team “starts with the end in mind,” the path from admission to transition consistently leads to shorter stays and fewer unnecessary readmissions.  This produces a journey of greater satisfaction for our patient, their family, and the primary care physician.

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