Preventing the occurrence of hospital readmissions is a key factor in improving outcomes, quality of care, and population health across the continuum of care. Hospitals are held accountable for improving transitions of care to avoid unnecessary readmissions as outlined by CMS guidelines.1
On June 15, 2020, Northern Light Health went live with a 30-day readmission prevention risk predictor. The predictor assists the care team in identifying patients who are at risk for readmission and to mitigate those risks through coordinated discharge and transition planning. The solution integrates relevant clinical Electronic Health Record (EHR) data into a single tool for managing and prioritizing at-risk populations of patients.
After implementing the readmission prevention prediction tool, other actions were also recognized as key elements of a comprehensive readmission reduction plan. These actions include providing patient education, completing care management (CM) assessment documentation and interventions, improving medication reconciliation, and collaborating with other interdisciplinary team members. In this case study, we will focus on hospital-wide readmission data from June 2021-November 2022 with a concentration on the specific clinical example of heart failure (HF) during the same time. Northern Light Health decreased overall readmissions from 9.8% to 9.1% and decreased HF readmissions from 17% to 14.5%, with a national average noted to be 21.9% .2 Two key factors impacted the improved readmission rates: 1) the increase in care manager engagements; and 2) an improvement in PowerPlan utilization to increase the standardization of care practice. Care management engagement improved from 108 enrolled patients to 188 enrolled patients within an 18-month period, and PowerPlan utilization increased from the utilization of 32 at its lowest point to 90 at its highest point during a 41-month review. The utilization of the Readmission Risk Predictor provided additional insight to the care teams and flagged patients at a high risk for readmission.