Outreach Beyond the Hospital Walls
"[Providers] understand that readmissions is larger than the hospital itself and they have to involve their community," says Babbitt. Her staff works with hospitals to develop the outreach. Hospitals are particularly interested in partnering with skilled nursing facilities. They are sharing data, including the readmissions report care, and helping educate SNF staff about high-risk patients who might be readmitted over and over again.
Almost all of the hospitals are reaching out to patients with a post-discharge telephone call. The purpose is to have a chat with the patients about how they are doing and to pick up any signs that the patient may be in distress. The call may be followed by a visit from home health.
One unexpected side effect of this program has been the buy-in of hospital administrators.
Certainly there is revenue associated with readmissions, but Babbitt says the hospital leaders she speaks to understand that a readmission is not the right thing for the patient. "We're not getting push-back anymore on reducing readmissions. They realize this is something that they absolutely have to do."