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The Most Overlooked Reason for Hospital Readmission

Posted by Danielle on March 17, 2015

katie cunningham nashville clinicianBy clinical transformation manager, Katie Cunningham

As a clinician, I know why most patients go back to the hospital--and it's not the reason you'd expect.


Having cared for patients in the hospital and home health settings, a major focus of my job at Medalogix is to impart the journey of the clinician and the patient to my Medalogix team members—After all, if our healthcare technology doesn’t benefit the clinician and patient, what’s the point?

While hospital readmission has always been an area of discussion, even more so since the Affordable Care Act introduced 30-day readmission penalties, there is a piece that is often missed in the conversation—a piece that in my opinion is consistently undervalued and underappreciated.


Patients are scared and alone.

After being cared for in a structured hospital environment where a nurse is a press-of-a-button away, going back home is a drastic change. Oftentimes it’s a 180-degree shift.

Here’s a snapshot of patients’ first days post discharge: While happy to be back home, patients are anxious. They’re often alone with a lot of time on their hands wondering, How many pills am I supposed to take? What are the side effects of this prescription? How do I get around my house in this new wheelchair? Will someone check in on me?

While home care nurses and therapists help greatly with the transition, we still need to make sure a patient feels supported when the home health clinician’s visit concludes. (Afterall, in the hospital patients receive continual care. In home health or home care that’s reduced to just a handful of hours a week.)

In many countries seniors often live with their children and this psychosocial adjustment isn’t as much of a struggle. Family surrounds patients and therefore their anxiety is eased. Unfortunately, that’s not the case in our country. Most seniors live at home alone without any social interaction.

I have high and low tech solutions to alleviate the psychosocial readmission risks.

home health clinicianHigh tech. Home health agencies can leverage healthcare technology to help support clinicians and patients during the critical period immediately following hospital discharge. Medalogix Touch is a healthcare analytics and workflow technology that identifies which patients are most at risk for hospital readmission (among other predictions like TIFs, falls and who would benefit from an additional care episode). Our predictive risk assessment accounts for the psychosocial element I describe above.

The technology doesn’t stop after identification though. It then helps home health agencies increase patient touchpoints with a call scheduling and Interactive Voice Response (IVR) function. (No, not a robotic call, but a real live male actor’s voice.)

These calling functions help clinicians, home health schedulers, clinical admins and branch managers streamline calls and patient feedback. Further patients learn to expect these calls and feel a sense of security knowing they’ll be receiving them. It makes patients feel confident that they’re going to be checked on and cared for by their home health provider.

Low tech. If your family member was just released from the hospital, go visit him or her. Not to necessarily care for him or her like a clinician would, but to offer some social interaction and make your loved one feel supported. Interaction goes a long way—especially in the weeks and months following a hospital stay.

Topics: Data and Analytics Review, Healthcare Industry


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