Three tips for reducing admissions in ACOs

Avoiding unnecessary hospital admissions helps accountable care organizations (ACOs) provide higher quality care to patients as well as reduce costs for their own organization. Under Medicare’s readmission reduction program, hospitals who see Medicare patients also have an even greater incentive for keeping patients healthy through outpatient-only care. But lowering admission rates involves not only preventing readmissions for patients who have already been hospitalized, but also avoiding admissions in the first place. And both of these require coordinated communication among everyone involved.


Ready to tackle the admission rate of patients in your ACO? Try these three tips.


1. Use Telehealth to Avoid Readmissions

Avoidable readmissions are a known drag on the profitability of ACOs and the healthcare industry industry in general. Not only does the new hospitalization create additional expenses, it also may indicate a gap in the quality and simplicity of the instructions and expectations the patient received upon discharge.


“Avoidable readmissions are a strong indicator of a fragmented health care system that too often leaves discharged patients confused about how to care for themselves at home, and unable to follow instructions and get the necessary follow-up care,” write Debra Ness and William Kramer for the Health Affairs Blog.


Avoid costly readmissions by harnessing telehealth services, along with push notifications and other reminders, to monitor recently discharged patients following a hospitalization.


Calling patients after they are home to address any questions about discharge instructions may help avoid more serious issues, especially if medications are not being correctly administered or if the patient does not understand what to do if new symptoms arise.


Also, using phone and text notifications to remind patients of follow-up visits can also help avoid delayed treatment of new or residual symptoms. As well, transtelephonic devices also can be deployed to monitor symptoms and track vitals for patients with chronic conditions.


Not all readmissions are avoidable, but using telehealth can help you avoid the ones that are.


2. Use Data Analytics to Treat Patients Across the Care Continuum

Reducing avoidable readmissions is just one method to control hospital costs in your ACO. Avoiding unnecessary admissions in the first place is another. But unlike readmissions, with a finite list of patients discharged in the last 30 days, avoiding unnecessary admissions requires ACOs to keep track of many more patients.


Tackle avoidable admissions by tapping into data analytics to treat patients in your ACO across the care continuum. Start by looking at all patients with chronic conditions, regardless of whether they have been admitted recently. Determine when they were last seen and if they are due for a screening or check-up based on evidence-based recommendations. Notify patients of maintenance treatment and screening options through phone or portal notifications.


Also, monitor your ACO data for patients who have recently been seen in an office, urgent care center, or emergency room with conditions that could escalate without additional intervention: wounds that might need to be checked, infections that may not respond to antibiotics, respiratory conditions that could worsen depending on the air quality, or other acute conditions that might trigger a chronic response. These patients would also benefit from a follow-up call, prescription reminders, or other check-ins to avoid more serious conditions.


Finally, look at all patients in your ACO for recommended preventive screenings and vaccinations.

Contact patients about flu and pneumonia vaccines, mammograms, PAP smears, PSA tests, and others, along with a list of ACO facilities near their homes where they can receive these services. If you are sending portal notifications, include a link to online scheduling, or if you are using an automated phone message, be sure patients can easily connect to a scheduling representative with the push of a button.


3. Use Communication Tools to Keep Providers and Patients Informed

According to a recent study published in JAMA Internal Medicine, poor communication is to blame for a quarter of preventable readmissions. Emergency physicians making the decision to admit, failure to keep outpatient physicians in the loop, and insufficient discussion of patient care goals were among the communication gaps that accounted for the high rate of readmissions. But so was patient inability to keep appointments after discharge and lack of awareness of whom to contact after discharge. Dr. Lauren Hersh, from the Thomas Jefferson University Hospital in Philadelphia, says patient health literacy may be lower than most physicians realize. She points out that one-third of Americans have trouble “understanding medication bottles, appointment slips, discharge instructions, medical and consent forms, insurance and medical bills or other health education resources.”


Don’t underestimate the importance of communication between providers and patients to help reduce length of stay, readmissions, and even avoidable admissions.


By using an integrated platform for care coordination, all providers can have access to the same data at the time they need it. Also, by using telehealth resources to follow up with patients on important healthcare instructions, and by pushing critical healthcare information to patients through mobile apps and online patient portals, ACOs can improve health literacy and avoid knowledge and care gaps that send patients to the hospital.

Chuck Rolfsen is the Chief Revenue Officer for Healthx. Through product design input and engagement strategy services, Healthx helps healthcare payers drive adoption and utilization of healthcare consumerism solutions including member portals and mobile apps.