Reducing Readmissions: What Happens in the Gaps?

Want to solve the readmission challenge, reduce health care costs, and improve outcomes? Then we need to look at what is happening in the gaps in our health and community systems. What are the gaps? Good question. Take a look at what is happening in our industry today.

asdThere is increasing fragmentation: Despite efforts to reduce complexity, our health care system and community network of services remain extremely complicated, and most people have no idea where to turn. As a result, they spend an inordinate and frustrating amount of time searching for the right resources. This is a big gap. Navigation is challenging and often contributes to crises, miscues, and significant barriers to getting the right help at the right time.

Spiraling health care costs are threatening state and federal budgets alike: The State of Minnesota, in collaboration with the US Department of Health & Human Services, is so concerned about the state’s and country’s ability to pay for health and long-term care that they launched the Own Your Future campaign this fall to better educate people about planning ahead to pay for their future care needs. The reality is that we all pay for spiraling health care costs in this nation – whether we are paying directly out of our pocket or through taxes used for government-run programs. These unsustainable costs create huge gaps in the care and support available to the public due to many factors, which include necessitating that programs and services be time-limited.

Major efforts to reduce readmissions have begun: The Patient Protection and Affordable Care Act (ACA) instituted wide-spread changes and innovations to focus efforts on reducing preventable hospital readmissions. The good news: those efforts are making progress. The tremendous energy behind care transitions, care management, health coaching, Medical Home, and accountable care organizations is designed to create a more systemic approach to well-being and break down the silos of excellence that have plagued our system for so long.

Unfortunately, almost all support services are time-limited: The reality is that even when support is put in place, whether it is Medicare Home Health Services, disease-specific care management, or care transitions, most often the supports ends after 30 days, 90 days or when a specific milestone is achieved. And when the support ends, gaps occur.

A recent gathering of Twin Cities thought-leaders, sponsored by Lifesprk, discussed the challenges of breaking what Lifesprk calls the Roller Coaster of Health Care Crises, and after a hearty and rigorous dialogue, their conclusions were unanimous: we need ongoing connection for people. There are too many gaps in our health and community-based networks, and when we allow those gaps to occur, we increase the risks of crises care crisis

In those gaps there is rarely an early warning system, there is little regular holistic oversight, and people become disconnected from their trusted advisors. Ongoing care management and community connectivity enables people to catch little issues early, helps them anticipate and plan for what is ahead, creates a trusted advisor who can provide consistent and proactive oversight across all settings, and makes it more likely that they will eliminate the roller coaster of crises that robs them of so much.

Share with us – how are you closing the gaps and increasing connectivity?