The 6th Annual Leadership Summit on Readmissions

Potentially preventable 30-day readmissions have been a major focus for government and commercial payers as a result of the Affordable Care Act. Despite the large number of discharge decisions made each year, there are no national, empirically derived decision support tools to assist in making these important decisions. As the number of bundled payment programs expand and the financial impact of 30-day readmissions increases, the use of post-acute care services and interventions will grow. In this session learn:

• The importance of identifying the post-acute care needs as well as their readmission risk at admission
• The impact of matching an individual patients needs with the appropriate care setting
• The ability to connect with post-acute care partners earlier leads to reduction in excess days

Care coordination is important to ensure patients receive care that prevents unnecessary hospital admissions. Although care coordination is a popular approach, it is often executed ineffectively. In this session hear:

• Best practices for identifying patients and the appropriate care coordination strategy
• How to standardize processes and connect with other care givers
• Strategies to implement and effectively use technology for care coordination

Technology has been implemented in many aspects of health care as a way to better outcomes and lower costs, and use of mobile apps is no different. Mobile apps can be used in numerous ways to increase efficiency and improve care, resulting in fewer readmissions.

• Discover how mobile apps can improve a patient’s compliance with discharge instructions
• Explore the role of mobile apps in home health care
• Discuss apps that assist in improving medicating adherence
• Uncover evidence that branded apps offered by a health care provider are more likely to be adopted than third party apps

SNFs often decide whether or not a patient is sent to the hospital. Understanding how they operate and their strategies for reducing readmissions is key.

• Hear how SNFs develop their own protocols
• Understand how the SNF works with the hospital
• Realize the tools a SNF needs to effectively lower readmissions

CMS’s Bundled Payment for Care Improvement (BPCI) initiative has provided both acute care and post-acute care providers an opportunity to learn how to collaborate toward influencing the “triple aim” – better health, better care, lower costs. Learn how a home health company, as the Model 3 Bundle Awardee, is working with acute care providers in this innovation model.

• Understand how the Model 3 bundle works
• Explore elements of a successful partnership
• Overcome barriers associated with the model
• Discuss actionable items you can apply in your organizations, whether participating in bundles or not

Joan Carroll studied for four years under Eric Coleman and understands his model well. She has developed several effective readmissions-reducing strategies for her hospital system and its diverse population of patients. In this session learn about:

• Factors that lead to a readmission and strategies to combat each one
• Elements to effective discharge planning
• How in-home coaches have become leaders in reducing readmissions

Studies show that a patient, especially after going through a traumatic health care episode in the hospital, retains very little information provided at discharge. To combat this issue and help keep patients healthy and out of the hospital, Mayo Clinic continues to develop approaches to educate patients and their families throughout their hospital stay and at home to help them be active and effective in self-care. In this session, hear preliminary results of their current work and:

• Understand how education can improve patient self-efficacy and activation to reduce call volumes, readmissions, and ED utilization
• Uncover effective ways to communicate with a patient in the hospital and at home
• Learn strategies for employing design thinking and rapid iteration to design and test new tools and processes to engage and educate patients and families

You can put the necessary protocol, care coordination, and continuum of care in place, but sometimes readmissions come down to understanding the population you serve and managing its common characteristics. In this session, understand an ER doctor’s point of view in managing frequent users, such as behavioral health patients who account for 50% of all ER visits.

• Learn common solutions for managing frequent users
• Realize strategies for working with patients who have a behavioral health condition
• Understand the role of the ER doctor in reducing readmissions