Issue link: https://beckershealthcare.uberflip.com/i/483154
15 Executive Briefing: Reducing Readmissions CipherHealth is a healthcare technology company committed to improving patient outcomes and experiences through enhanced com- munication and care team coordination. Our solutions reduce preventable readmissions, increase HCAHPS scores, and foster patient and clinician engagement. In addition to the three core patient chal- lenges — discharge instructions, medica- tion adherence and follow-up care — many hospitals rely too heavily on risk stratifica- tion tools to predict patient outcomes, ac- cording to Mr. Silverzweig. While risk stratification tools can be use- ful, there is no replacement for direct communication with patients about their wellbeing after returning home from a hospital visit. Asking direct questions about their recovery and assessing prog- ress through their care plans is the best way to determine if a patient requires in- tervention, he says. How care coordination can prevent unplanned readmissions Often times, frontline healthcare workers are the greatest tool hospitals have to im- prove post-discharge care and prevent re- admissions. "Care coordination is all about connect- ing the dots," said Mr. Silverzweig. "It's about giving the care team the right in- formation at the right time. For instance, one piece of information about a patient in different people's hands can be the difference between an unplanned read- mission or simply a phone call or con- sultation." From the early adopters to the hospitals that have just recently jumped on the post- discharge wagon, the methods for coordi- nating care are almost as diverse as the patients themselves. Some hospitals and healthcare facilities utilize clinical call centers to follow up with patients after they've been discharged while other hospitals assign the respon- sibility to individual nurse managers, care coordinators or — in the cases of more specific cohorts and patient populations — health coaches. Leveraging technology as a post-discharge care tool In addition to having workers take ac- countability for following up with patients, hospitals can utilize tools that, while rela- tively simple in their concept, can make a world of difference to both patients and their loved ones. Addressing issues such as misunder- standing discharge and medication in- structions may be as providing patients with easy access to the instructions after they've returned home. Another tool CipherHealth created, called Echo, does just that. Echo allows clini- cians to record important medication or care instructions during the discharge pro- cess with a patient. The recordings can then be played back to the patient during their Voice call or when a patient calls in on their own to hear their Echo. By recording discharge instructions, hos- pitals have seen higher engagement rates with Voice post-discharge, as well as, in- creased understanding about medication and discharge instructions in general. Patients can also play recorded discharge instructions and information for fam- ily members, caretakers and loved ones, putting their minds at ease, according to CipherHealth Vice President of Marketing Katharine Walker. For many hospitals that have taken the steps to improve care coordination and have implemented post-discharge tech- nology tools, the results have been practi- cally instantaneous, according to Mr. Sil- verzweig. "At some level, there is an immediate benefit and cultural change that is appar- ent after implementing this system," said Mr. Silverzweig. "The stories we get about patients that were likely going to be read- mitted but, because of a post-discharge tool, were saved or were connected with an appropriate avenue for care, start to come up in the first days or weeks after implementation." n