Discharge Management: Our Approach to Curbing Readmissions

Discharge Management: Our Approach to Curbing Readmissions

Nearly 34 million times a year, a patient leaves a U.S. hospital. The circumstances are as unique as the individual patient. And the stakes are high for every single one. Fortunately, the best practice in patient care also happens to pay off in value-based care. So, as part of our standard discharge management service, Wellvana’s Care Team attempts to reach patients within 48 hours and maintain close contact for the next 30 days. Often, nurses find that without relatively simple interventions, a patient could easily make an avoidable return trip.

Nearly 34 million times a year, a patient leaves a U.S. hospital. The circumstances are as unique as the individual patient. And the stakes are high for every single one. Fortunately, the best practice in patient care also happens to pay off in value-based care. So, as part of our standard discharge management service, Wellvana’s Care Team attempts to reach patients within 48 hours and maintain close contact for the next 30 days. Often, nurses find that without relatively simple interventions, a patient could easily make an avoidable return trip.

A Care Note on a Close Call

A costly ER visit avoided and a patient’s life changed in a recent discharge management encounter.

A patient in Arizona suffered a stroke. He had to be air-lifted to a hospital in Nevada. Then he was discharged to a family member’s home in California.

He was prescribed blood pressure medication but he and his caregiver didn’t recall any instructions at the hospital. Now he was in another state without a doctor, and his readings were dangerously low.

He was becoming lethargic. His breathing had turned shallow. The family called a new cardiologist. But they were only seeing established patients.

Fortunately, Kristina Miller, RN, with Wellvana was handling the standard discharge management. She reached the patient’s wife and immediately recognized the urgency of the situation. Kristina placed a priority alert in the EHR at this patient’s home practice in Arizona.

Given the life-and-death risks, the practice immediately held a telehealth visit to straighten out his medication and set up a plan going forward.

The Stopwatch Starts at the Hospital Door 

From time to time, Wellvana’s nurses will reach a patient who did schedule a follow-up appointment. But the follow-up is more than a month out.

Especially for Medicare patients, this will not do. 

They are far more likely than commercially insured, Medicaid or uninsured patients to end up back in the hospital within 30 days. And readmissions tend to cost more than the first go round —12.4% more, according to latest AHRQ brief. 

Blood diseases, digestive problems and respiratory conditions have among the highest costs on the second go-round.

We want to eliminate as many readmissions as possible. Not only is it just good patient care, but these return trips to the hospital take a double bite out of the potential shared savings for providers. 

And the impact of a prompt follow-up within seven days has shown a pretty clear benefit, as in a 2019 study published in JAMA and others. 

Based on the last six months of 2023, Wellvana is seeing progressively positive indicators that Discharge Management makes a measurable difference when compared with a control group.

  • 94% of patients contacted by Wellvana agreed to enroll in the 30-day support. 

  • 7- & 14-day follow-up office visits improved by 20%. 

  • 30-day readmissions decreased 25%. 

A Doctor Weighs in on Discharge Management

I used to be in the hospital every day. If you’re a family physician of a certain age, you probably were too.  

Before driving into my practice, I’d round on my patients in the hospital. Not anymore.

Now, I can barely get our local hospital to let me know when I have a patient admitted. I know hospitalists fill an important role and are great at their jobs, but they don’t know our patients like we do. And in my experience, they don’t have much interest in looping me in. 

Patients usually go home clutching a fist-full of prescriptions which results in one of three outcomes:

  • They decide to stop taking their other meds.  

  • The meds interfere with their usual prescriptions.  

  • They don’t fill their hospital prescription because of cost or confusion. 

If a patient spends a week or two in medication limbo, I can bank on a readmission. That’s why at my practice in Jackson, Michigan, we aim to see them within a few days — never more than a week.  

Wellvana’s Discharge Management Support

The best thing that can happen upon discharge is for patients to follow up with a doctor they trust and know well. Many of these may be patients who don’t come in for preventive care as much as they should. A discharge follow-up is a great opportunity to make sure their conditions are documented accurately for benchmarking purposes. 

Our nurses are working in the background to support your patients through the critical 30 days after hospitalization. 

How It Works

How It Works

Upon Discharge
Upon Discharge

Wellvana receives an alert when patients are discharged through statewide ADT/HIE feeds. Often, this is information practices were not privy to previously. 

First Contact
First Contact

Within 48 business hours, the patient should receive a call from Wellvana’s Care Team to make sure the patient has a follow-up appointment scheduled.

Patient Enrollment
Patient Enrollment

If they agree to enroll, they will get periodic calls from a Wellvana nurse to make sure they’re following their discharge care plan, address caregiver needs, and assist with medication management. 

Ongoing Support
Ongoing Support

Patients will receive support by phone along with educational and encouraging emails and letters for 30 days following discharge.

Beyond Discharge Management
Beyond Discharge Management

If needed, the patient can transition into Wellvana’s ongoing care management. 

There is no cost to patients for this service, which is sometimes hard for them to believe. But this is the beauty of a partnership with Wellvana.

When the only goal is keeping patients as healthy as possible, the financial rewards work themselves out because they’re perfectly aligned with the best patient care. 

This is the way medicine was meant to be.

Share

See how your practice could perform as part of Wellvana’s ACO.

See how your practice could perform as part of Wellvana’s ACO.

Mature practices in our ACO see double-digit savings rates, on average, while patients in our care management program go to the hospital 25% less with a 16% decrease in their medical spend. Start your way to Wellvana by calculating your value-based care potential today.

Mature practices in our ACO see double-digit savings rates, on average, while patients in our care management program go to the hospital 25% less with a 16% decrease in their medical spend. Start your way to Wellvana by calculating your value-based care potential today.