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6 Steps to Reducing Readmissions with Care Coordination

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by J. Hunter Young, MD, MHS

Dr. Young is Ankota's Chief Medical Officer, and serves jointly as Assistant Professor of Medicine at the Welch Center for Prevention, Epidemiology, and Clinical Research, and Core Faculty of Johns Hopkins Bloomberg School of Public Health. In these roles, Dr. Young is involved in population health programs and community based initiatives that are aimed at decreasing readmissions and lowering the overall cost of care. As managing Care Transitions has emerged as a critical element in reducing avoidable readmissions, health care providers are looking for information to guide them in the creation of these programs. A recent paper noted below studied some early programs to both assess their success and identify the common elements that make them successful. 

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The Medicare Coordinated Care Demonstration program tested the effectiveness of 15 care coordination programs with regards to their ability to decrease Medicare expenditures, improve quality of care, and improve patient satisfaction. During the program’s first 4 years, only 2 of the 15 programs reduced hospitalizations.1 In a recent analysis published in Health Affairs in 2012, Randall Brown and colleagues reexamined the impact of the 11 programs that were extended beyond 4 years.2 Four programs significantly reduced the number of admissions by 8 – 33% among the high-risk subset of their enrollees. These high risk Medicare beneficiaries represented 18% of the Medicare population and 37% of Medicare fee-for-service expenditures.

The authors were able to identify 6 distinguishing features of the successful interventions, which may guide providers in developing their own programs to better coordinate care, improve patient outcomes, and reduce avoidable readmissions:

  • Approximately one face-to-face interaction between the patient and care coordinator per month
  • Promotion of a good working relationship between the care coordinator and the patient’s physician by embedding the care coordinator in the clinic or assigning a physician’s patients to 1 care coordinator
  • The care coordinator served as a “communication hub” ensuring that all providers had key information about their shared patients
  • The care coordinators supplemented patient education with motivational interviewing and other behavior-change techniques
  • The care coordinators provided robust medication management with access to a pharmacist or the physician as needed
  • The care coordinators contacted patients during hospitalizations and assisted with their care transitions

Therefore, in effective care coordination programs, the care coordinator facilitates transitions, takes a lead with medication management, and facilitates behavior change through education and support. In addition, the care coordinator serves as a hub for interactions among providers. Programs incorporating these features were effective in both urban and rural contexts and in a variety of organizational settings demonstrating broad applicability of care coordination.

Common themes among these 6 elements is coordination of activities and communications among provider care teams, and between caregivers and patients. Early programs such as these, while producing encouraging results, have been criticized for being limited in scale and are typically not automated. The lack of automation could suggest that the success of these programs is very limited, but that's not a valid conclusion. With the emergence of Care Coordination technology from Ankota, highly efficient and large scale coordination among providers is possible immediately. This facilitates better provider-to-provider communications, as well as provider-to-patient & family communications. Care plans are evidence based, easily shared among all providers, and interventions are well timed and coordinated in addition to being very efficient. This technology applies well to Avoidable Readmissions programs, Community Based Care Initiatives, Care Transitions, and post discharge planning and follow up. Contact Ankota using the button below to learn more 

Learn How Ankota Technology Reduces Readmissions

1.         Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. Feb 11 2009;301(6):603-618.

2.         Brown RS, Peikes D, Peterson G, Schore J, Razafindrakoto CM. Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff (Millwood). Jun 2012;31(6):1156-1166.


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