By Robin Hill

Reducing hospital readmissions has been a top target of value-based care and population health management initiatives since the terms were coined. And for good reason.

The Agency for Healthcare Research and Quality (AHRQ) says patients readmitted within 30 days of discharge cost hospitals $41.3 billion, which puts them among the most expensive episodes to treat. While some readmissions are unavoidable, most are not – making them ideal targets for disrupters in the population health management space.

Since the goal of value-based care is to improve health outcomes while reducing costs, finding ways to keep patients from being readmitted to the hospital is fast becoming an imperative – and a key metric. One of the most significant of these strategic initiatives is giving clinicians the ability to monitor patient health outside of the acute care setting.

Through the use of turnkey remote care monitoring platforms, clinicians can empower patients to do more to manage their own health and remain compliant with their plans of care long after they return to their homes. Additionally, the ability to collect biometric, behavioral, and other key data from at-risk patients on a continuous basis means those patients are never fully discharged from the care they require.

Yet there is another factor that comes into play – the patient’s active participation in the remote care management program. The most powerful remote care technology in the world won’t succeed in keeping patients healthy if those patients don’t use it properly, which means actively working to improve patient engagement is critical to delivering the maximum benefits. The reality is, patients who are confident in the technology, enthusiastically generate accurate data, understand the impact their participation has on their overall outcomes, and feel empowered to troubleshoot issues as they encounter them will have the greatest success.

The time for isolated interventions is past. Studies show that comprehensive remote care programs are far more effective at reducing unplanned hospital readmissions than individual encounters. Ensuring they achieve wider adoption and are successful in driving systemic care improvements, however, requires a few essential components:

Start with the path of least resistance. Typical value-based outcome goals for chronic heart failure (CHF) patients are reducing length of stay and 30-day readmissions, making this condition a natural place to start a remote care management program. After all, those outcomes (along with greatly improved patient satisfaction) are easy to track. From there, the program can be easily extended to COPD, hypertension, and diabetes, which naturally leads to programs that support core uses cases such as smoking cessation. Health systems that began remote care management programs in one obvious area are now using them to manage multiple acute and chronic conditions across many service lines.

Keep implementation simple. Since patients will have varying comfort levels with technology, deploying it across a broad population can be difficult. The most effective solutions will be those that are designed with the targeted population in mind. For example, while there are always exceptions, older populations are often uncomfortable with or actively resistant to learning new or complex technologies. Since this population is the one most likely to require remote care for a variety of acute and chronic conditions, it’s important to design the program in a way that removes any fear or discomfort. That may mean using pre-configured devices to simplify the patient experience, which will result in higher compliance with onboarding and engagement. Conversely, a younger, rising risk population may prefer to use its own smartphones, tablets, etc. It’s all about giving patients what they want and need to be successful.

Develop engaging content. YouTube has become one of the most important educational tools in our world today. Whatever you need to do, you are likely to find a video that explains how to do it. Healthcare organizations can use this to their advantage by creating educational videos that answer basic questions and embedding them within their applications. Patients can then use them to answer those questions themselves rather than going to a clinic or taking up staff time trying to explain relatively simply concepts to patients. A combination of videos, health tips, and teach-back questions can head off many simple inquiries, ensuring that patient interactions with the care team are focused on higher-value, critical care issues.

Encourage communication. Giving patients the ability to take advantage of features such as embedded video conferencing lets them take greater control of their care. Rather than feeling like they need to wait until there is a serious issue to reach out to their care team, video conferencing makes it easy to share information with their providers more often. As they become more comfortable with the concept they become more engaged, which not only improves outcomes; it increases patient satisfaction.

Automate information-gathering. One way a health system can enhance its consumer-facing image is by using engagement solutions to automate many best practice processes such as those in a post-discharge area. An automated survey that comes to the patient’s device can ask basic questions such as “How are you?” “Do you have a fever?” “How is your pain?” or “Do you have redness or swelling around your incisions?” without the need to tie up a clinician’s time. Patients feel that they are not being neglected waiting for someone, and any answers that trigger concern can be brought to the immediate attention of the care team. Bringing the survey to patients through a low-cost engagement solution is far more effective at obtaining data than asking the patient to log in to an online portal. The technology can be as simple as a secure text that opens a smartphone browser to deliver an app-like experience while leaving no patient data footprints on the device when the interaction is completed.

Integrate your RPM platform into your overall engagement strategy. Keep your care team from having to spend its time chasing down the 85 percent of patients who disengage once they return home by integrating your engagement platform with your portal and app strategy. Patients can then be guided to more information within your complete care ecosystem.

The last barrier is down
When the Centers for Medicare and Medicaid Services (CMS) issued its final 2019 Physician Fee Schedule and Quality Payment Program, it created an unprecedented opportunity for any hospital or health system that wants to reduce unplanned 30-day readmissions. This landmark change opened the door to reimbursement for connected care services that enable providers to manage and coordinate care at home.

The doors to remote care management technology are now open wide, but it’s important to understand that technology alone doesn’t guarantee success. By adopting a strong patient engagement strategy, health systems and clinicians can drive better outcomes, create recurring revenue, and improve the patient care experience.

About the author: Robin Hill is the Chief Clinical Officer at Vivify Health. She is a Registered Nurse with over 30+ years of healthcare experience which includes acute and post-acute care. The last 12 years have been focused on healthcare IT in the acute and post-acute space. Robin is responsible for leading the clinical and product teams at Vivify Health and is passionate about creating engaging services and solutions for customers and patients.