Rising to the Challenge
Turner West, MPH, palliative care leadership center director at Lexington, KY-based Hospice of the Bluegrass, says there is no one-size-fits-all approach to creating readmission intervention programs.
Turner West, MPH
"A wide range of models exist to reduce hospital readmissions. There is variability among these models largely based on the patient population served, available community resources, and the type of hospital, so it is difficult to say a specific intervention is feasible or replicable in all settings," he says.
"Generally, however, successful interventions to reduce hospital readmissions require identifying patients at high risk for readmission, collaborating with the patient and family on a specific discharge plan, medication reconciliation, and effective discharge planning and care coordination with community providers—primary care, specialty care, home health, skilled nursing and hospice."
West says communities with relatively high levels of resources can supplement hospital-based readmission intervention models with technology and a constellation of patient-focused specialists.
"Some of the more successful models are innovating by leveraging technology and developing community partnerships to support patients and families," he says. "There are transition programs, health coaches and navigators, high-risk case managers, telephonic support and tele-health programs that we can all learn from."
Christopher Cheney is the senior clinical care editor at HealthLeaders.