Avoidable Readmissions: What If There Was a Pill . . .

In examining the results from a Centers for Medicare & Medicaid (CMS) pilot program, the Washington Post found that only one of the 15 programs in the study not only improved patient outcomes but also cut costs.

holding-handsThe article is appropriately titled “If This Was A Pill, You’d Do Anything To Get It.”

There are two interesting key points with this article: first, that despite the stellar results achieved, CMS has decided to cut funding for this program, and will not attempt to scale it (more on that another time). Second, it identifies the key elements of a successful pilot program that not only reduced avoidable readmissions but also helped Medicare save money.

What are those key elements? Take a look:

  • Weekly check-ins in the patient’s home: “Home is where elderly patients spend most of their time. It’s where they take their medicine and eat their meals, and it’s where they fall into funks and trip over the corner of the carpet. It’s where a trained medical professional can see a bad turn before it turns into a catastrophe,” writes Washington Post journalist Ezra Klein.
  • Patient discovery: As the nurse profiled in the article explains, “You have to find out why a patient isn’t taking their medicine.” It may seem irrational that people don’t comply with doctor’s orders but the reality is that their life may have some opposing goals, and to truly get patient engagement we need to understand the ‘whys’ behind the behavior.
  • Trusted advisor: An ongoing, long-term relationship with the same nurse builds a trust that enables the nurse to influence the patient’s behavior.
  • Freedom to ‘ask anything’: With a long-term relationship, barriers are broken and patients feel more comfortable asking questions and sharing concerns. This allows the nurse to gather better and more in-depth knowledge about the patient, and can play a significant role in changing behavior.
  • Early detection: The ongoing visits in the home also enable the nurse to more easily identify subtle changes in the patient, and address them before they become expensive crises.

Organizations that truly want to reduce avoidable readmissions – and save money – should look for these key elements in their ACOs partners and post-acute providers.

And despite Medicare’s reluctance to further fund the pilot program, a growing body of research will show that this back-to-basics approach with strong ongoing connectivity to the client and the family will be the building blocks for changing the experience for patients and their families in the future. It creates a new experience that produces sparked lives with a lower price tag.

Change on!

Want to know how Lifesprk compares to the pilot program and these key elements? Call our Lifesprk Navigation at 952-345-8770, or email us.