Why is a Readmission Reduction Program Important?

Readmission is when a patient is admitted to a hospital within a short period of time after they have been discharged. The Centers for Medicare & Medicaid Services uses 30 days as a benchmark timeframe in defining readmission.

Readmission signals that the original treatment and care was not adequate. Needless to say, this is an important metric for healthcare providers. High readmission rates represent a lack of quality and ability on the end of physical therapists. As such, readmission reduction programs are essential for healthcare providers, hospitals, and physical therapy clinics alike to consider.

Key Steps for Your Readmission Reduction Program

1. Check-In With Patients After Discharge

The most important thing that healthcare providers and clinics should understand is that care management does not end after discharge. In fact, the exercises and behaviors that a patient engages in upon discharge are key to recovery.

Soon after a patient is released, physical therapists should call patients and conduct post-care assessments. This assessment should consider patient understanding of his/her condition as well as well as scheduling for follow-up appointments.

This initial check-in call establishes a baseline for future communication. This step also communicates to patients that physical therapists are invested in their full recovery, even outside of the clinic.

2. Assess Patient’s Self-Care Capacity

Another important question: can patients adequately take care of themselves? Even if patients have a full understanding of their treatment plan, they might not have the ability to follow through with this plan.

Some criteria to keep in mind are:

  • Patient’s ability to perform activities of daily living (ADL’s) such as walking up and down stairs, showering, picking up mail, etc.
  • Patient’s ability to eat and go grocery shopping for food
  • Patient’s access to an emergency contact or someone who they can call for help

It is advisable for physical therapy clinics to recommend caregivers for patients who do not meet these criteria. This is the best possible way of ensuring that patients are getting the care they need.

3. Evaluate Patient’s Home Environment

Home safety evaluations are essential to a physical therapy clinic’s readmission reduction program. These evaluations are conducted in order to assess the safety of a patient’s home. Safety evaluations are important because the environment plays a big role in a patient’s recovery.

Ideally, a home safety evaluation is conducted before a patient is discharged. This way, professionals can adequately prepare the house for the patient’s arrival. 

There are many factors to consider when creating a safe environment for a patient. One such consideration is anything that can be a potential fall risk. For example, home safety agencies can identify general house clutter, lack of safety railings in bathrooms, loose rugs, and slippery floors. These safety issues must then be brought to a caregiver’s attention.

4. Install Medical Equipment

Along with home safety evaluations, patients must have necessary medical equipment on hand in their houses. Patients should be able to have access to good quality equipment that can support their recovery.

Home health is a separate field in and of itself. There are a lot of aspects that go into making patients comfortable in their own homes. There may be a few accommodations that must be taken care of to ensure a smooth transition from hospital to home. Some examples include stair lifts, specialized walkers, and raised toilet seats.

5. Set Up Emergency Alert Systems

Patients need to have someone to reach out to in the case of an emergency. Emergency alert systems facilitate this process. Install these systems for patients who have a high risk for falls or are otherwise weak.

Although healthcare providers may set up these systems for patients, emergency alerts will do nothing if patients do not utilize them. As such, instruct patients on their use and emphasize that they should wear these communication devices at all times. An especially strong area of concern is when the patient is in a bathroom or shower.

Besides emergency alerts, patients should have important contacts ready on speed dial. As with the emergency alerts, ensure that patients know how to call someone on speed dial.

6. Introduce Community Resources

Patients benefit from community resources in addition to their healthcare needs. Make sure that patients have a high quality of life and have opportunities to satisfy their social and cultural needs. Possible community resources to consider include:

  • Transportation programs: This is one of the most important resources for a patient to have access to. Senior citizens or those who are in weak conditions can especially benefit from public transportation offerings since they may not be able to drive themselves.
  • Senior center activities: The elderly generally lack opportunities for social interaction – and such interaction has proven benefits to health. Introduce elderly patients to game nights or live music events at local senior centers. This can be the perfect opportunity for senior citizens to get to know others while enjoying social activities.
  • Volunteer opportunities: It is often good for patients to get out of the house and stay active. Volunteering is a good way for patients to engage in the community while getting out of the house and getting some exercise.

Support groups: There can be support groups for patients with similar conditions – for example, the Alzheimer’s Association. Access to such a group encourages patients to reflect on their condition and how it is affecting their lives. Support groups, by their nature, are also an amazing way to form relationships with others who are in similar situations.

7. Establish a Regular Line of Communication

The first step of checking in with patients after discharge is an important step. However, more importantly, healthcare providers should remain in contact with patients.

Follow-up phone calls can be a great way to stay in contact. Establish a regular schedule for reaching out to patients. For example, call patients every week, then decrease the frequency as they recover.

AC Health’s mission statement is in line with the idea that care management does not end after discharge. AC Health offers a mobile application that allows for a quick and easy line of communication between patient and doctor. Through this platform, physical therapists can create playbooks and upload videos of recommended exercises and treatments. Physical therapists can also set up in-app push notifications to remind patients to follow through with their respective treatment plans. Patients can then reach out through the app if they have any questions about the treatments.

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At the end of the day, it is clear that a physical therapy clinic’s readmission reduction program reflects on the quality of their involvement with patients. Readmission will be greatly reduced if physical therapists take a hands-on approach with patients and continue to manage their care after discharge.