The Patient Experience: Reducing Readmissions
By Roberto Colón, MD, system chief medical officer, Premier Health
Unplanned readmissions remain one of the most significant challenges in health care. These excess care encounters are not only a source of patient dissatisfaction but also lead to overutilization of resources and capacity. Premier Health is dedicated to improving the patient experience and reducing hospital readmissions through a comprehensive, system-wide strategy focused on three primary tactics listed below.
Multidisciplinary Focus on High-Risk Congestive Heart Failure (CHF) Patients
To address high readmission rates among patients with CHF, we implemented a multidisciplinary approach across all our facilities. Each facility identified CHF patients with the highest readmission rates and is developing individualized care plans tailored to their needs. These care plans will ensure continuous and cohesive care. A critical component of this strategy is the integration of an EPIC alert that will flag high-risk CHF patients whenever they seek care at a Premier Health facility. This alert system ensures that health care providers are immediately aware of the patient's high-risk status, prompting them to take the necessary steps to prevent readmission. Additionally, primary care providers received detailed communications about these patients to facilitate planning and coordinated care throughout the entire care continuum.
Enhanced Post-Discharge Access
Research has demonstrated that a reliable post-discharge plan is one of the most impactful measures for reducing readmissions. Therefore, our second tactic focuses on improving access to post-discharge visits within seven days of leaving the hospital. Ensuring timely follow-up care, we aim to address potential issues before they lead to readmission. While focused on certain Premier Physician Network patients initially, this initiative will gradually expand to encompass all at-risk patients including those receiving care from community practices, federally qualified health centers, and private offices
Revamped Palliative and Hospice Care
Chronic illnesses and end-of-life care present significant challenges, often resulting in repeated hospital admissions. Our third tactic focuses on revising our system strategy around palliative and hospice care to better meet the needs of these patients. While we currently offer palliative and hospice services across our hospitals, we recognize the growing demand for these services as the burden of chronic illnesses increases. A multidisciplinary team is evaluating our current capabilities, ambulatory needs, and academic initiatives in this space.
A Unified Effort for Better Outcomes
Preventing unnecessary readmissions is a top priority for our entire health system. Success will require the alignment and collaboration of all team members, from emergency departments and hospital care teams to ambulatory offices and home care providers. By working together and focusing on these three key strategies, we will improve the health of those we serve.
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