Electronic Health Reporter

Guest post by Lee Horner, president, Stratus Video.

Many healthcare organizations refer to the at-home, at-risk patients as the “sickest of the sick.” Unfortunately, these patients may receive inadequate care and attention after being discharged and often rely on emergency medical services and/or the ED to answer questions and provide care in non-emergency situations. The model for treating these patients and attempting to keep them at-home (and not back in the hospital) has not changed substantially in decades. In an attempt to minimize re-admissions, hospitals may schedule case managers and/or nurses to physically visit these patients at-home in an effort to help the patients stay on track with their adherence.

However, this continuum of care model is not sustainable. The budget and resourcing implications are significant when most of the staff’s time is spent behind the wheel vs. in front of the patient. Significant opportunities exist for telehealth solutions to bring the care closer to the patient — at a more convenient and cost-effective manner for all involved.

Why Reducing Readmissions Matters
From the patients’ perspective, returning to the ED and potentially being re-admitted is disruptive and stressful for patients and family. Patients may be put at an additional risk for hospital-acquired infections and complication. Returning to the hospital can also lower the rate of patient satisfaction and weaken overall outcomes.

From the perspectives of health systems and health plans, readmissions are costly. Since the introduction of HRRP (Hospital Readmission Reduction Program), hospitals that exceeded the national average of readmissions for specific conditions (within the 30-day window) have been penalized by a reduction of payments across all of their Medicare admissions. More than half of hospitals in the HRRP program were penalized the past five years, resulting in $528 million in withheld Medicare payments. Re-admissions can also negatively impact measures in Hospital Compare data, levels of provider satisfaction and the health system’s overall reputation in the community it serves. Re-admissions cost more than $26 billion annually but $17 billion is considered avoidable.

What Happens Today
Keeping at-risk patients at-home is critical to reducing re-admissions and the associated consequences.  Typical discharge programs with in-person appointment schedules often fail the at-home, at-risk patient, the providers, and the healthcare system by insufficiently engaging the patient at the point of discharge and upon returning home. The rates of patients being readmitted are significant:

• Nearly 20 percent Medicare patients are readmitted within 30 days.
• 34 percent of Medicare patients are readmitted within 90 days and 56 percent within 1 year.
• 64 percent received no post-hospital care between discharge and readmission.

What happens in-hospital and at-home which leads to this situation? In-hospital experiences can adversely affect health and contribute to substantial impairments during the early recovery period, an inability to fend off disease, and simple mental error. As a result, patients may leave the hospital deprived of sleep, experiencing pain and discomfort, without sufficient nourishment, and with medications which may alter cognition and physical function.

When a patient is discharged, the patient may continue to face physical, emotional and even financial issues, depending on one’s condition, health history and home environment. A patient may be discharged without adequate instructions and information for self-care and follow-up. The patient may be provided with comprehensive verbal instructions but quickly forget the detailed instruction. Written instructions may be provided to the patient but the patient may fail to keep the information handy and/or share the information with family/friends serving as caregivers. Internalizing the discharge program and being able to practice self-care may also be negatively impacted by a patient’s level of English proficiency, health literacy, socio-economic status, gender and cultural background.

When preparing for a patient’s discharge, a hospital has many priorities to address.  Tests/consultations need to be concluded on a timely basis. Medication lists are updated. Paperwork needs to be prepared and shared with the patient. And, transportation may need to be arranged on behalf of the patient. As hospital staff members are stressed and overworked, care providers may not be able to spend as much time as they desire on instructing patients on how/when they are supposed to re-engage with their care team.

How Telehealth Can Help With the Transition of Care
The optimal transition of care program should be designed from the patient’s perspective while leveraging the realities of the hospital’s existing workflows. A high-tech and high-touch patient engagement program will help this segment conveniently access care from home and prevent return trips to the ED. With telehealth, care providers and at-home, at-risk patients can participate in video calls – and include a pharmacist, a specialist and other care team members – to discuss progress and adherence in real time. Video-based platforms are increasingly being used to bring care closer to the patient’s home. Benefits include:

• Saving travel time and expenses for all involved. Patients will not need to worry about the time and expenses for transportation to a follow-up appointment. Instead, patients can conduct a virtual visit with their care team, from the convenience and comfort of their home. Care providers will not need to spend windshield time driving to patients’ homes. Instead, care providers can “see” more patients, more often and from a more convenient/centralized location.
• Identifying potential issues before drastic intervention is needed. Telehealth provides medical staff with the opportunity to share patient education and explain to patients (and their caregiver) what is now different about their medications, why those changes were made, and what side effects may occur.   Video-based calls can enable care providers to recognize verbal and visual signals which may indicate an emerging issue or condition.
• Bringing comfort to potentially isolated patients. Family, friends, and/or neighbors are not always nearby nor available to help at-home/at-risk patients after discharge.  Video-based chats with their care providers can help these patients feel less isolated and help encourage these patients to adhere to their treatment plan on a more frequent basis.

Convenient communication is critical to keeping this patient segment at-home and on-track with their treatment plan. With telehealth, patients and care providers can quickly and easily connect to ensure that patients are engaged and on-track with their progress.