Recently, a long-time customer came to us looking for an innovative, cost effective way to reduce readmissions. Like many organizations, they have processes in place to identify a small percentage of discharges that are at risk for readmission. They strongly believed, however, that there was an opportunity to further reduce readmissions but did not have the resources to reach everyone or the tools to risk stratify the population.
Together, we developed an automated post discharge assessment solution:
Each discharge not marked as a readmission risk automatically receives a four question assessment 24 hours after discharge. The assessment gathers patient-reported feedback about treatment plan adherence and other, key readmission risk factors.
All patient responses are catalogued in real-time on the CareWire platform and, when responses are outside of a pre-defined criteria, the care coordination team is automatically notified. They are able to reference the patient’s responses through the platform and follow-up with a phone call to the at-risk patient.
Since implementing the solution, response rates have been greater than 54% (measured monthly), sometimes as high as 61%. Of those responses, 11% of patients were prioritized for immediate follow-up. Readmission rates for this population have been reduced by ~30%.