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Helping Patients Avoid Readmission

Helping Patients Avoid Readmission

Hospital readmissions: They’re one of the biggest thorns in our sides. They’re not good for patients, they tie up our emergency departments and inpatient units and they affect our reimbursement rates and our quality ratings.

According to the Agency for Healthcare Research and Quality (AHRQ), addressing three key areas prior to discharge helps prevent adverse events: medication reconciliation/review, patient education and structured discharge communication that covers medication schedules, pending tests and studies, and follow-up needs.

But even with safeguards in place, we all know what can happen. Patients arrive home and get confused about which medication to take when. Maybe they experience another health symptom, but they don’t want to call their doctor or they hope it resolves on its own. Unfortunately, notes AHRQ, there’s no consensus on how to ensure patient safety after hospital discharge, but as you’ll see in our cover story, Johns Hopkins Medicine is focusing on empowering patients to practice active self-care, connecting them to appropriate outpatient resources and providing higher-level assistance, including home visits, to patients at higher risk of readmission. The goal is to prevent problems from happening or resolve them before they necessitate hospital-level care.

This focus has made an impact on our bottom line. In 2016, for instance, The Johns Hopkins Hospital reduced its readmission rate by 12.66 percent, and a catch-all after-care clinic at the Johns Hopkins Outpatient Center saved an estimated $1.4 million in avoided hospitalizations.

This issue of Managed Care Partners also provides an update on our Johns Hopkins Medicine Alliance for Patients (JMAP) accountable care organization, a partnership between the Office of Johns Hopkins Physicians and the Office of Managed Care and Population Health. Scott Berkowitz and his talented team are continually expanding the services offered to JMAP’s 39,000 beneficiaries, from a care management plan for high-risk members to helping older adults with physical disabilities age in place.

In addition, we highlight Johns Hopkins’ efforts in precision medicine. With centers for prostate cancer and multiple sclerosis already in place and several more in the works, Johns Hopkins physicians are harnessing the power of big data to help pinpoint the treatment—or watchful waiting protocol—that is most likely to be beneficial for each individual.

We welcome surgeon Jonathan Efron to his new role as senior vice president for the Office of Johns Hopkins Physicians, overseeing the activities of all physicians within our system.

Until next time, have a great summer! 

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