So how can a hospital readmission prevention program actually work?  Over the next few posts I’ll look at each of the three components.  In this one I’ll cover Patient Identification & Prioritization.

It’s important to identify patients as close to the time of their discharge from the hospital as possible.  When a physician cares for his patients in the hospital, he clearly knows the discharge date so he can communicate it to the Readmission Prevention Program.  But it has become more and more common that the primary care physician does not see his patient in the hospital when they have been admitted.  In his place, a hospitalist does the inpatient management.  In this situation, how do the physician and Readmission Prevention Program learn about the patient’s hospitalization and discharge?

• The hospitalist could call or e-mail them, but that’s not very efficient.
• Sometimes health insurance companies have Readmission Prevention programs for non-Medicare patients.  They may have a staff person at the leading hospitals to identify patients that are being discharged.
• Alternatively, the health plan may call discharge planners at the hospitals to learn about their health plan members who have been discharged.
• In more and more locations, Health Information Networks (HIN) are being set up to enable one health care provider to share information with another. The patient needs to authorize the HIN to share their information with the health care providers that care for the patient.   But once that’s done, the hospital’s information can be passed to the PCP’s office and the Readmission Prevention Program.
• In our ACO, one of our hospitalists has developed a hand held application that automatically sends e-mails to the PCP and the Care Coordinator with the Readmission Prevention Program when the hospitalist sends a patient home.

As far as Patient Prioritization or Stratification, some of these Readmission Prevention Programs use clinical criteria, such as the reasons for the hospitalization to determine which patients should be contacted after hospital discharge.  Sometimes a scoring system is used, but that depends on someone at the hospital scoring the patient and that score getting transmitted to the Readmission Prevention Program.  A very popular readmission risk scoring tool is the LACE Tool which calculates a score based upon,

• Length of stay – how long the patient was in the hospital.
• Acuity – whether the patient was a hospital inpatient or not.
• Co-morbidities – how many other diseases the patient has.
• Emergency room visits – the number of these visits in the past 6 months.

A score over 10 indicates that the patient has a high likelihood of readmission and should be contacted promptly after he is sent home.

In the next post I’ll talk about what is covered in the Outreach component of these Readmission Prevention Programs.

For Your Health – Dr. Bob