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​​Reducing Avoidable Hospital Readmissions with Home-Based Medical Care


Reducing unnecessary hospital readmissions is about more than patient statistics. It’s about the 72-year-old patient who transitioned to home rehab but didn’t follow her pain management regimen and rehab protocols. Or the 64-year-old patient with congestive heart failure (CHF) who was discharged from the hospital with instructions to quit smoking and go for a walk each night, but he did not.  

The result? Both patients are likely to be readmitted to the hospital. As their doctor, you never like to see this outcome. You’ve spent years treating these patients, and you’re personally invested in their wellness. 

Thankfully, we can change this narrative. This article identifies six strategies to reduce hospital readmission for at-risk patients and improve post-hospitalization patient outcomes with home-based medical care.

Doctors discussing a patient readmitted to the hospital again
In the United States, as much as 27% of hospital readmissions are preventable. 

An Estimated 27% of Non-Emergency Hospital Readmissions Can Be Prevented

Twenty-seven percent of hospital readmissions are preventable, per hospital data. The impact on you and your practice? Lost time, resources, and the associated costs for not only your practice but also the patients!

Why is it Important to Reduce Hospital Readmissions?

If unnecessary hospital readmissions were addressed, it would be a significant win for everyone involved. While there are many, below are three primary impacts of addressing avoidable hospital readmissions: 

  1. Doctors can provide a higher quality of care 
  2. Lower medical costs for patients and their families 
  3. Patients have better care outcomes

Reducing unnecessary hospital readmissions can improve the overall quality of care that doctors can provide by lessening the strain on the doctor’s time and facility resources.  

In addition, it’s no secret that a return trip to the hospital comes with an additional financial burden for patients. Patients and their families can suffer lost wages, missed work, additional medical costs, and other financial hardships due to hospital readmissions. When looking at the economics for both patients and healthcare providers, these avoidable events result in billions of additional healthcare costs each year. Yet, most importantly, reducing hospital readmissions is a key piece of the puzzle for providing the best care outcomes for patients. Many doctors and scientific studies recognize the improved health outcomes of incorporating home-based medical care into a patient’s post-hospital recovery plan. 

What is your strategy for preventing avoidable readmissions? Here is a good place to start:    

Producing better care outcomes for patients and their families is at the forefront of Prospero’s care mission. Our home-based medical care solutions combat many causes of avoidable readmissions and highlight strategies doctors can also use to counter them.

Home-based medical care provider meeting with patient transitioning to care in the home
Ongoing care support following hospital discharge is a key strategy to lowering readmission rates.  

Main Causes of Unnecessary Hospital Readmissions

There are three primary causes of increased readmission risk: 

1. Inadequate Care Transitions

Transitional care can be a complex and involved process. Care coordination helps with medication reconciliation, progress tracking, and other vital elements of transitional care.  

Fractured communication between a patient’s healthcare practitioners or their home-based medical provider can result in inadequate patient home care.

Strategy: Optimize Care Transitions with a Care Support Team

Effective care transitions require clear, consistent communication between the patient, their home-based medical care provider, and hospital staff. Prospero specializes in building individualized care plans to support each patient’s recovery.       

Optimized care plans often include regular visits with doctors, nurses, physical therapists, mental health practitioners, social workers, and home care professionals. This care support team provides a smooth transition from the hospital setting to a patient’s home. 

“At Prospero, we work really hard to try and reduce unnecessary emergency room visits. And what I mean by that is emergency room visits that could be resolved at home, and many patients and families go to the emergency room because they don’t have a Prospero team to call in the middle of the night. And they don’t have a team who will come to the home the next morning to help figure out what’s wrong and to improve and modify the treatment plan. So we very much try to reduce unwanted and unnecessary emergency room visits by providing a level of availability and responsiveness.” 

 – Kris Smith, MD, MPP, Chief Clinical Officer, Prospero Health 

2. Patient Disengagement or Non-Compliance with Their Care

Improper recovery and eventual readmission can occur due to poor rehabilitation habits or inappropriate use of prescribed medication. While doctors try to provide the information that patients need to follow in a recovery plan, it can often be a lot of information for your patients and their families to absorb.  

Patient disengagement can mean the difference between their ability to manage their recovery effectively and a trip back to the hospital for an exacerbated condition.

Strategy: Ensure Patients and Their Families Understand Post-Discharge Instructions

Patients must understand their post-discharge instructions before they leave the hospital. 

Our advice: Review the care plan with the patient in detail. Make sure to include any family members who are involved in the patient’s care as well.

Strategy: Improve Patient Engagement and Education

A powerful way to lower a patient’s readmission risk is to prioritize the patient’s awareness and education about their care plan – and include their family members! Prospero’s insight: Educating caregivers and patients about medications and physical therapy helps them manage the condition and stay on the path to recovery. 

Strategy: Identify High-Risk Patients

Extra levels of care and consideration post-discharge help to minimize a high-risk patient’s chance of being readmitted. But first, you must identify these patients and develop a tailored care plan.

Older man reading his prescription medication
Appointment follow-ups provide an additional layer of support to help prevent errors such as taking the incorrect dose of a prescribed medication.

3. Errors with Follow-Up Care or Medication

Many patients intend to follow their care plans. In reality, they may forget to take the correct medication dosage or miss a follow-up appointment. Follow-up care is crucial to a patient’s overall recovery. It can help avoid unnecessary hospital readmission. 

Strategy: Schedule Appointment Follow-Ups

A follow-up appointment helps keep your patient on track with their post-discharge plan. It is also a dedicated time to check-in, discuss any new or worsening symptoms, and receive further clarity on recovery steps, as needed. 

Certain Medical Conditions Produce Higher Readmission Rates

Complex conditions, such as CHF and chronic obstructive pulmonary disease (COPD), drive high levels of hospital readmissions. Careful transitions and monitoring can help keep complex patients with CHF and COPD on the mend–and out of the hospital!  

Congestive Heart Failure

CHF is one of the leading causes of hospital readmission. Roughly 24% of patients are readmitted for renal failure and sepsis within 30 days of their initial discharge. The task at hand is to improve transitional care plans to help prevent readmission and morbidity among this patient group.   

Chronic Obstructive Pulmonary Disease

COPD affects more than 12 million adults. It is the third leading cause of hospital readmissions and costs hospitals, taxpayers, and patients over $15 billion annually in readmissions alone. Close monitoring for new or worsening symptoms keeps these patients out of the hospital.   

Strategy: Find the Right Home-Based Medical Care Provider

Some patients live alone, while others live with an ailing spouse. These realities can put your patients at risk for hospital readmission. Prospero supports physicians by making the transitional care process seamless and more engaging for patients.

Doctor explaining to a female patient her medical care plan
Choosing the right home-based medical care provider can make all the difference in our patients’ lives and help prevent unnecessary hospitalizations.

6 Strategies for Preventing Avoidable Hospital Readmissions

Readmission risk starts with the discharge process, and it lasts until the patient has healed or learned to manage their condition. Six strategies that help lower avoidable readmission rates include:

  1. Optimized care transitions 
  2. Ongoing care support 
  3. Clear patient instructions 
  4. Patient education & engagement 
  5. Identification of high-risk patients 
  6. Appointment follow-ups

A home-based medical care provider can help. Studies show that patients cared for by a home-based service during transitions of care were 60% less likely to be readmitted within a 30-day period when compared to those who were not. Patients rely on their medical team to teach them about their conditions, any required medications, and follow-up instructions. Prospero’s patient-centered approach can help alleviate issues that pop up during the recovery journey.

Older female experiencing chronic medical issues at home
When patients disengage from their care, they are at a higher risk for hospital readmission. 

Choose Prospero Health for Home-Based Medical Care

When Prospero Health works with doctors, we complement a patient’s traditional medical care to improve health outcomes, quality of care, and lessen the individual and macro-level financial burden of hospital readmissions.

For years, provider organizations have relied on Prospero Health to provide top-quality care through a patient-centered approach and care solutions that are designed to keep our clients healthy and safe. Our care model helps minimize patients’ risk of developing medical complications post-discharge. 

Contact Prospero to Start Reducing Avoidable Hospital Readmissions

Together, we can help reduce avoidable hospital readmissions. For more information on how home-based medical care can lower readmissions, contact Prospero Health.