The Journal of mHealth Vol 2 Issue 2 (Apr 2015) | Page 27

Using Technology to Manage Care Transitions & Reduce Readmissions

Using Technology to Manage
Care Transitions and Reduce
Readmissions
Article by Douglas Naegele and Janica Lee
The healthcare industry is increasingly
conscious of effective care transition
management to reduce hospital readmission rates. Because hospitals can be penalized for excess hospital readmissions,
a greater focus is placed on improving
discharge and follow-up care. US hospitals, for example, have reduced cardiac
readmission rates by up to 50% by simply granting greater attention to this issue.
Consequently, new programs have sprung
up across hospitals – ranging from lowtech to high-tech solutions. While many
believe that drug adherence is the largest
determinant of readmission, scheduling timely follow-up appointments and
enrolling in proper follow-up care also
play a role in reducing readmission.
Changing Workflows
Research shows that patients only retain
between 10% and 50%1 of the instructions communicated to them. Recently,
hospitals have rolled out new initiatives
to bridge that gap. A group of hospitals
in Pennsylvania – St. Vincent and Jameson Health System – found promise in
a non-tech solution. Patient navigators
within hospitals filled the specific role of
improving patient care transitions. They
are responsible for conducting patient
follow-ups, connecting patients to local
care services, and scheduling physician
appointments. A 60%2 reduction in
readmission rates was noted following
implementation, demonstrating that a
modification in workflow alone can have
an impact on reducing readmissions.
Telephone and IVR
Not everybody has the time and
resources, however, to create and staff
new roles. Over the past ten years,
telephone follow-up has emerged as
one of the tools hospitals implement
to ease transitions and follow-up with
patients.  In a 30,000+ patient study,
those that received at least one follow-up
call within 14 days were 23%3 less likely
to be readmitted within 30 days.

Recently, IVR technology has automated
and standardized some of the outbound
calling and inbound patient data collection. Geisinger, an eight-hospital system
in Pennsylvania, implemented the Geisinger Monitoring Program; an IVR to
monitor recently discharged Medicare
patients.  Patients who enrolled in GMP,
along with the hospital’s case management
had a 44%3 reduction in 30-day readmissions vs. a risk-adjusted control group.
Enter the Apps
A number of app-centric interventions
have emerged to guide patients through
the pre- and post-hospital phase.  This
area of ‘patient time’ is critical because
if certain things go undone (medication
fills, follow-up scheduling etc.) – readmission rates are shown to rise predictably.
Patients using Mayo Clinic’s app had a
20% readmission rate compared to the
60% of those who did not.4 The app,
showcased at the 2014 Annual American
College of Cardiology Scientific Session,
helps reduce cardiovascular risk factors in
addition to readmission rates. Patients are

able to record BP, glucose level, physical
activity and dietary habits. They also have
access to educational activities that encourage healthy lifestyle behaviors for cardiac
patients. When the app is used in conjunction with cardiac rehab, patients saw
greater improvements in health compared
to the group who only received the latter.
Created by Boston Children’s Hospital,
ReadySetGo aims to better prepare par