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Reducing Avoidable Hospital Readmissions with Care Coordination Technology

Readmissions have and continue to serve as a key indicator of the quality of care patients receive from the US healthcare system. The US spends over $41 billion annually on adult 30-day all-cause readmissions. Reducing readmissions can have dramatic impacts on the financial outcomes of hospitals, skilled nursing facilities, and other care providers.

Decreasing Readmissions at a Critical-Access Hospital

CHI St. Anthony Hospital, a 25-bed critical access hospital in rural Oregon, launched an investigation to identify what was causing readmissions at the facility after an analysis showed that at least 50 percent of patients returning to the ED were better suited for a lower acuity setting.

Using Collective’s real-time data, CHI St. Anthony tracked and monitored emergency department utilization and readmissions. Staff discovered that patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) were the top groups contributing to readmissions because they weren’t being given adequate discharge instructions. 

Understanding this, Joyce Bailey, VP of Patient Care at CHI St. Anthony, instructed her team of care managers to provide extra support and follow-up care to COPD and CHF patients within 72 hours of discharge.

Bailey explains, “Every month, we continue to improve. We now have the capabilities to not only understand what drives our readmission rates, but also to combat preventable readmissions at the source.”
In less than three years, CHI St. Anthony has been able to decrease readmissions from 8 percent to less than 2 percent, an overall reduction of 78 percent in all-cause 30-day readmissions.

Helping Skilled Nursing Facilities Avoid Penalties

In recent years, readmissions have become a priority for skilled nursing providers due to value-based purchasing models that cut Medicare fee-for-service rates if providers fail to meet readmissions requirements. These penalties affected nearly 75 percent of skilled nursing facilities (SNFs) last year. 

Marquis/Consonus Companies owns and maintains a network of post-acute, rehabilitation, and residential care facilities throughout Oregon, California, and Nevada.In 2018, Marquis rolled out Collective’s platform at three Oregon facilities with a combined readmission rate as high as 19 percent in certain months. 

Armed with data that extended beyond the four walls of an individual SNF, Marquis staff were able to receive an instant notification if a former resident sought treatment at a nearby hospital. Staff could then work with the hospital to determine if a patient could return to the Marquis facility for treatment—avoiding a costly hospital readmission.

Being able to track patients across care settings helped Marquis decrease readmissions by 60 percent at the three Oregon facilities in less than six months. This drop allowed Marquis to avoid penalties and earn nearly $115,000 in reimbursements.

Care Collaboration as the Backbone of an Award-Winning Readmissions Reduction Program

Built in 2005, Legacy Salmon Creek Medical Center offers a range of technological advances and innovations to patients in Southwest Washington. Staff at Legacy Salmon Creek realized that reducing readmissions needed to start in the emergency department (ED), using it as a center for decreasing readmissions.

Using the insights and capabilities of the Collective platform and network, Legacy Salmon Creek created a customized process—including an ED readmissions algorithm that standardized the assessment of patient needs and considered alternatives to readmissions.

First staff minimized duplicative services, then brainstormed ways for patients to get support in lower-acuity settings. As a result, Legacy Salmon Creek made over 600 referrals to primary care providers, specialists, and other providers within the first year of the program. Within 24 months, Legacy Salmon Creek was able to reduce all-cause 30-day readmissions by nearly 25 percent. Additionally, the hospital saw a reduction of over 80 percent in ED visits.

If overcoming preventable readmissions and maximizing clinical and financial outcomes is a priority for your organization, talk to our team today. We’d be happy to share how we’re driving true care coordination with real-time, bi-directional insights with access to the nation’s largest acute and post-acute network.

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To learn more about reducing and preventing avoidable readmissions, read this white paper.

Brittany Eastman
Content Marketing Specialist