Care Transitions – Focus on 30-Day Readmissions
Medicare Fee for Service beneficiaries had 1.7 million readmissions within 30 days in 2015; CMS estimates that about 1 million of these readmissions were potentially preventable at a cost to Medicare of nearly 14 billion dollars. A study from the 2013 Medicare Claims file looked at factors associated with transfers and readmissions among Medicare patients initially presenting at rural facilities. The study found that patients discharged from hospitals in large rural settings had 32 percent higher risk of unplanned readmissions when compared to those discharged from urban hospitals. Additionally, patients who were discharged from small rural settings had a 42 percent higher risk of unplanned readmissions.
The results of this study combined with a variety of factors such as poor transportation, poor access to care and multiple comorbidities, suggests a strong need for high quality care transitions. RAZR’s target is to reduce hospital readmissions in recruited hospitals. We offer member hospitals a variety of evidence-based tools, training, and IT resources to succeed in reducing readmissions and in meeting their target incentives. We provide readmissions prevention expertise in the following categories:
RAZR is experienced in successfully assisting hundreds of hospitals with changing the behaviors of patients, families, and clinicians. RAZR success primarily depends on the utilization of the following tools:
Behavior Medical Adherence Assessment Scale (B-MAAS) – RAZR uses B-MAAS to identify the “at-risk” population for medication compliance.
Adherence Management Coaching/Adherence Improvement Plan (AdM Coaching) – RAZR uses AdM Coaching to create a relationship with the patient and their family to help them realize and understand consequences that may affect the ability to follow the discharge plan of care.
Implicit Association Test (IAT) – RAZR uses IAT to measure attitudes and beliefs that people may be unwilling or unable to report.
Current Best Practices
RAZR utilizes the following risk assessment and care transition models as best practices to assist hospitals with improving care transitions and reducing readmissions.
Better Outcomes for Older Adults through Safe Transitions (BOOST) – RAZR uses BOOST as an effective tool for reducing unnecessary readmissions and improving transitions of care by looking at 5 key elements and 8 risk factors.
Re-Engineered Discharge (RED) – RAZR uses RED to focus on improving the discharge planning process by implementing processes improvements and methodologies to improve the discharge planning process AND post-discharge care.
Include, Discuss, Educate, Assess, Listen (IDEAL) – RAZR uses IDEAL as an evidenced-based discharge planning process that focuses on transitions of care.
Transitional Care Model (TCM): RAZR uses TCM to prevent health complications and rehospitalizations of chronically ill, elderly hospital patients.
RAZR’s approach to formulating an innovation strategy has been successful because we focus our innovative strategies around clear, concise, and identifiable customer needs. We believe that diverse and creative perspectives are crucial for successfully identifying customer-specific innovative strategies.
Telehealth – RAZR encourages the use of electronic information and telecommunication technologies to support and promote long-distance health care, patient and professional health-related education, public health, and health administration.
Telemedicine and Mobile Health are components of telehealth. RAZR’s experience with mobile health solutions is exemplary. We played a primary role in the development, testing and launch of a mobile solution for primary care physicians, hospitals and patients suffering from chronic disease (i.e. cardiovascular health, diabetes, COPD) and transitional care management.
Applied Behavioral Science – RAZR is experienced with the application of multidisciplinary behavioral research and knowledge to identify and resolve behavior problems. (Please refer to column one “Changing Behaviors”.)