Readmission Reduction Success Kit

Is there a silver bullet to eliminating preventable hospital readmissions?

Health systems continue to place intense effort on their readmission reduction strategy, but the efforts are not yielding the desired success.

Hospital readmissions within 30 days of discharge is an important health system measure. Not all readmissions are preventable, but there are many preventable cases within the 20% of Medicare members who are readmitted in that period.

While fewer hospitals were assessed penalties in 2021 versus 2020, there were still 2,500 (80% of CMS evaluated facilities) who faced penalties because of their readmission rates – even with Covid-19 data being eliminated from the analysis.

With today’s emphasis on episodic outcomes and value-based care, health systems need to know where patients are going, where they’re coming from, how PACs and external partners are managing patient care, and where they have opportunities for improvement.

Many strategies have been proposed and implemented, and research in the field of transitions of care has shown that effective communication plays a significant role in preventing readmissions. Specifically, when patients are being transferred to post-acute care (PAC) providers after discharge, communication can break down. This has led to health systems relying on stars ratings, outdated claims data, and narrow PAC networks to reduce readmissions, yet simplifying communication between health systems and PACs has been neglected.

NIH research has shown many factors that increase readmission along the continuum of care including insufficient follow-up, lack of care coordination, and poor communication between providers on each side. Their research concludes that better coordination of care between acute and post-acute care exhibits the most potential to reduce readmission rates.

1. Readmission reduction plans should include goals beyond financial measures

Health systems shouldn’t limit their readmission reduction success to financial metrics. Success from a holistic perspective includes increased accuracy, consistency, productivity, and employee morale.

Metrics must reflect broader, more transformational ambition for readmission reduction to realize a true return.

With broader goals, teams can innovate and strengthen communication and infrastructure resulting in better financial outcomes. Teams only focused on financial success goals, can come at the cost of staff burn-out.

Health systems need to think differently about how to achieve their readmission objectives. There must be a change in mindset to look beyond financial aspects of readmission and toward reduction of stress factors and workload on the staff. A focus on non-financial indicators is a first step toward innovative transformation creating sustainable, long term success.

2. Understanding population health: PAC current state and limitations

Health systems often have narrow PAC networks that they have chosen based on stars ratings, claims data and quality factors of the provider. These systems are also staffing population health team members to physically work in or regularly visit PACs in their narrow network.

Both initiatives have merit but are not easily scalable, rely on historical performance versus real time data, and do not address the challenges of antiquated communication channels. Additionally, with the rise in home health and patient’s choosing to go outside of a hospital system’s preferred PAC provider, it becomes increasingly difficult to coordinate and communicate with the appropriate people who are managing a patient’s care.

NIH studies indicate there are no clear or widely accepted standards around direct communication between health systems and PAC providers.

Today’s common communication channels between health system staff and PAC staff include back and forth emails, missed phone calls, unanswered voice mails, faxes, and text messages. Often health system staff members do not even know the phone number or the email of every post-acute provider in their referral network.

The preference for value-based contracting is becoming more prevalent in the PAC market which compels PAC providers to align with health system objectives. Health systems reward PAC providers that engage in more value-based contracting arrangements with potential bonus payments, shared savings and additional volume directed to their facilities. As the market appetite for risk increases so does the desire to engage and strengthen collaboration.

Olio’s extensive experience in the health system, physician group, and post-acute industries has shown there are 5 key indicators that need to be effectively communicated between the two parties:

If both health systems and providers can easily access and coordinate care on these 5 key indicators proactively, they can support each other effectively and most importantly support the patient and reduce readmissions.

3. Embrace automation to get population health and PACs on the same team

The best way to solve for the challenge of getting everyone on the same page around these 5 key indicators is to embrace automation that creates transparency and enhances staff experiences.

Automation is widely used to improve efficiency by reducing per unit costs and improving staff experience, but hospitals can be leery of “over-tooling” staff with complex systems.

The reality is staff live in a world where technology has simplified how they conduct business. Technology applications have changed the way they access transportation, food, ecommerce, finance, or banking. Digital platforms and automated communication channels have elevated their expectations to access information and communicate instantly wherever they are through computers and mobile devices. Health system and PAC staff have expectations of automation easing administrative burdens because that is how they engage with businesses in their lives. They desire communication tools and apps that streamline their interaction around patient care.

Documentation burden is one of the primary drivers of staff dissatisfaction, burnout, and ultimately turnover. Not only does it involve ample below-license work, but it also distracts from patient care. Staff are inundated with information coming from multiple communication channels regarding patients in PAC settings, and much of the information has little significance that can change the outcome of readmission.

Finding automation that minimizes the number of manual touchpoints required per task across each use case results in staff and clinicians working at the top of their license. People are wired to use technology that allows them to communicate with ease – it is in their DNA in today’s economy.

The healthcare process around patients going from a hospital system to a PAC setting require human involvement, but with effective automation teams can operate efficiently and engage with each other in a simplified fashion. When reviewing workflows that can be automated, health systems need to look for simplified ways to get everyone on the same page. Reducing touchpoints and inspiring effective communication around the 5 key drivers of readmission success creates staff loyalty and satisfaction with their work.

Innovative consumer experience technologies found in other markets are entering the healthcare space in many areas, including readmission reduction. Health systems should look for tools modeled around innovative communication between two parties that allow staff to spend less time trying to connect with each other and more time focusing on patients that need their attention.

Leaders who have navigated communication challenges and invested in automation tools that enhance communication point to a few keys for success.

Finding the right automation tool for your team can be overwhelming, so it is important to engage hospital leaders and PAC leaders to automate communication in a way that works for your organization.


About Olio

Olio redefines how population health teams manage patients in post-acute care settings. The Olio platform gets everyone on the same team by providing an easy, immediate way to communicate. Olio connects health systems to all post-acute providers, drives scalable PAC behavior change, and tracks engagement to generate better outcomes.  Olio operates on a PMPM pricing model (cents not dollars) and guarantees clients see a +10X ROI.