White Paper: The Role of Technology in Reducing Hospital Readmissions for LTPAC Patients
Hospital readmission rates among long-term, post-acute care patients have historically been high. Medicare defines readmission as any patient who returns to the hospital within 30 days of discharge.
Readmitting patients to the hospital following an acute health event is emotionally and financially draining for patients and their families. It can also sow mistrust in the healthcare system and prevent people from seeking necessary medical treatment during future medical events.
These readmissions for LTPAC patients are costly to patients who have to spend more money on deductibles, copays, and other expenses. Readmitting patients also funnels resources from other patients. Because of these and other reasons, Medicare has aimed to reduce readmission rates over the past 15 years. Programs aimed at achieving this goal have had success, reducing rates from 21.5% to 17.8% for targeted conditions from 2007 to 2015.
Advances in technology are helping to reduce these rates even further. Electronic health records (EHR), software that enables remote visits, and other technological innovations improve patient access to care and facilitate effective communication between hospitals and caregivers at your LTPAC facility.
Here, we explore the role technology plays in improving LTPAC to improve patient outcomes and reduce readmissions.
The Cost and Impact of Avoidable Readmissions
Hospital readmission rates in the United States have fallen, on average, since 2015. In 2020, the national average was 14.56%, with rates across the country ranging from approximately 11.2% to 22.3%.
Large urban centers with more hospitals and higher discharge rates had higher readmission rates. About 11% of readmissions are considered to be avoidable. Common causes of these preventable readmissions include diagnostic errors, insufficient care planning, and treatment errors.
When you have to readmit someone to your facility following discharge, you not only pay for their bed, treatment supplies, staff, and other costs; you also risk penalties from the Centers for Medicare and Medicaid Services (CMS). If a patient is readmitted to your facility less than 30 days following discharge, you may be penalized up to 3% of your Medicare revenue.
Readmissions are a fact of life in LTPAC, but if you start experiencing too many of them, you could end up eating into your budget in more ways than one. In addition to seeing your Medicare revenue drop, these readmissions may decrease patient trust, which in turn can damage your reputation and negatively impact your ability to recruit new patients to your facility.
The Health Outcomes of Readmissions
CMS has set readmissions as a quality standard because a high readmission percentage indicates that you’re not thoroughly treating patients. Frequent readmissions also negatively impact patient health. Patients going in and out of hospitals or long-term care facilities may experience infections and other complications.
Being readmitted to a facility multiple times for the same condition is also stressful for patients and their family members. If the initial readmission was caused by care quality, your patients may become sicker than they were when you or the referring hospital initially treated them.
Often, patients who most need coordinated care are the ones who have limited access to healthcare resources. Inadequate insurance is one of the most significant barriers to healthcare access. If your patient is uninsured or has limited insurance, they are more likely to forego preventive screenings that make conditions more manageable. These patients may also suffer from other underlying conditions, such as Type 2 Diabetes, that make treatment plans more complicated.
The Role of Care Transitions and Coordination in Reducing Hospital Returns
Successful treatment often depends on a patient’s ability to follow through with medications and other treatment plans. As a long-term, post-acute care provider, you play a key role in facilitating aftercare.
Successfully coordinating care transitions benefits patients and reduces hospital returns. Communicating with your patient’s hospital or primary caregiver lets you create customized treatment plans and evaluate specific details of their condition. You also receive a complete patient history, including comorbidities that could impact their recuperation while in your facility.
Coordinating care makes treating your patients more efficient by reducing redundancy. Since you have access to their complete medical records and treatment plans, you don’t have to duplicate tests or ask your patients the same questions multiple times.
Technology as a Solution
Technological advances in health care have made it much easier for you to coordinate with your patient’s hospital, primary care physician, and specialists on their team.
Clinical Documentation and Data Accuracy
EHR systems offer a comprehensive view of a patient’s medical history. Current platforms make it easy for you and other care team members to transfer vital information that informs how you care for each patient. Accessing your patients’ complete records reduces medical errors and improves accuracy.
EHR platforms also play a role in mitigating risks. You can set up alerts and reminders, log medication allergies and other important information, and access lab results, care plans, wound management, and other treatment notes without correlating multiple files.
An added bonus to EHR is that you can submit anonymized patient data to researchers to better understand patients with specific conditions. You can also identify patterns among your patient groups to appropriately intervene when needed. For example, knowing how a certain medication impacts your patients with hypertension will help you personalize care plans for future patients with the same condition.
Predictive AI and Risk Stratification
The ability to analyze data with artificial intelligence is impacting businesses across industries, including healthcare. Entering a patient’s health records into an AI-powered platform lets you predict specific outcomes to create a detailed care plan.
AI assesses various data points and assigns risk to patients based on historical data from people with the same condition. Classifying people by risk level allows you to prepare for a patient’s complexity. Examining the various risk factors for each patient helps you target potential treatments and interventions.
Monitoring individual patient data informs potential outcomes of various drugs and treatments and helps you anticipate whether or not a patient might need to be readmitted to the hospital within 30 days. When data points to a high-risk patient, you can closely monitor their treatment and develop care plans to improve their chances of being discharged successfully.
Care Coordination and Interoperability
Communication is a key factor in successfully transferring a patient from the hospital into your skilled nursing facility. Using interoperable EHRs allows you to seamlessly coordinate care between multiple specialists.
Without interoperable systems, you and your team have to manually enter patient data into the system. Your administrative team also has to coordinate with the hospital to access your patient's acute care records.
The right EHR systems let you submit and receive patient records faster while staying in compliance with privacy regulations. Everyone on your team has access to the patient’s complete medical record, which reduces errors and improves treatment speeds. Members of your patient’s caregiving teams can also access notes and other data in real time, which reduces the risk of redundancy.
Between 2017-2021, hospitals electronically sharing care records via EHRs increased by over 50%.
Remote Patient Monitoring
Healthcare professionals had to get creative to follow COVID-19-related restrictions. In Canada, eight acute-care hospitals measured the effectiveness of remote patient monitoring versus in-person monitoring in 2021. Patients opting for remote monitoring measured their own vitals at home and photographed their wounds, sharing the results with caregivers daily. The study showed that after 30 days, though more patients in the virtual care group reported errors in their medications, these were quickly corrected, and the patients reported lower pain levels.
Patients can wear smart sensors and other devices at home to monitor their vital signs around the clock. This way, their caregiver can assess the data and intervene as needed. Remote patient monitoring also gives caregivers the option to remind their patients to take medications and monitor how their wounds are healing.
Another recent study monitored patients with respiratory and cardiovascular disease. These patients pose a higher risk for hospital readmission because their diminished heart and lung function can lead to complications. The study, conducted over four months, assessed high-risk patients using digital monitoring tools at home following discharge from the hospital. Each patient met weekly with their caregiver through videoconferencing while a project manager entered vital data into the system every day. Results showed that remote monitoring reduced readmissions and visits to the emergency department within three to six months.
Challenges and Considerations
Technology dramatically improves your ability to manage patient care and reduce hospital readmissions for LTPAC patients. However, there are some challenges when incorporating technology into your LTPAC.
Adoption Barriers
Upgrading your systems to the latest technology is not always easy. Migrating your EHR platform alone can cost more than $10,000 annually. If you have a small practice with few users, you’ll probably spend about $1,200 per year to use the system.
You also need to train your team on the new EHR system and provide ongoing support during the transition period. When you’re transitioning to a new platform, your operations will inevitably slow down until your team adapts.
When choosing a new EHR system, look for one that is interoperable with other systems you’re already using, or you could end up having to replace more than one system. If you choose to work with two systems that can’t communicate, you lose out on automation, workflow optimization, and other benefits that the new EHR platform should provide.
Regulatory and Compliance Concerns
Emerging healthcare tech, including AI and remote monitoring devices, have the potential to revolutionize how you treat patients. However, there is some cause for concern. Firstly, you are required to protect your patients’ private information. Any new technology you integrate into your workflow should be able to transfer data without compromising patient records.
Wearable sensors and other remote monitoring devices can also be vulnerable to hacking, so it's crucial to take steps to protect access and train patients on how to use them.
AI can quickly analyze data to provide accurate risk assessments for your patients. However, there is some concern over how these systems collect and share user data. There is no consistent protocol to protect data on AI-powered platforms. If you use one, encrypt it and monitor access to keep patient data safe. You can also randomize historical data by removing identifying information about your patients. Removing names and other details makes the dataset anonymous and reduces the risk of accidental data breaches.
Strategies for Overcoming Implementation Challenges
The best way to manage implementation challenges is to choose the right vendor. Do your homework and compare various systems. That way, you’re getting a system that meets your needs at your allocated budget. Before signing up for a system, ensure it is interoperable with systems you already use, such as billing software.
Work with a partner that offers support and training materials, and train your team on the new system in stages. Have your most tech-savvy team members test the system first and slowly roll it out to everyone. Your experienced team members can then help train others.
Mitigate regulatory and compliance challenges by working with experienced vendors who understand HIPAA and other rules. Create a risk-assessment strategy for every piece of new technology. When you’re looking for new systems, classify them based on how they may impact patient safety.
High-risk technology requires more oversight. Designate someone on your team to set up and fully approve the system before you integrate it into your existing platforms.
The Future of LTPAC Technology and Readmission Reduction
As tech evolves, it brings new possibilities for patient care to reduce hospital readmissions.
Emerging Trends in Health Tech for Post-Acute Care
In recent years, much of the focus for health tech has been on diagnostics, imaging, and other caregiving tools. These tools are great for improving how you treat and manage your patients, but other systems have been overlooked, including EHR.
Fragmentation is one of the most significant challenges facing EHRs. Many facilities aren’t using the same EHR, complicating the coordination process and delaying health record acquisitions. For example, you may have to wait until after you’ve admitted your patient to access their surgical records and other medical data. If your patient has comorbidities, you may have to track down records from multiple providers to accurately assess the patient.
Luckily, emerging EHR systems are catching up. EHR vendors are increasingly focused on interoperability for faster data exchanges. New EHR platforms also make sharing information with your patients easier, allowing them to take a more proactive role in their care.
The Role of AI, Automation, and Telehealth in Care Transitions
We’ve already covered how AI can help you classify patients’ risk levels to tailor their care, but AI can do much more. Many emerging healthcare platforms use generative AI to take notes during patient visits. This allows caregivers to focus fully on the patient while still getting detailed visit notes.
Since these tools integrate with EHR and other software, the notes automatically populate into patient records. Your nurses and other caregivers don’t have to spend as much time on administrative functions. AI also flags inconsistencies in a patient’s chart so you can adapt caregiving strategies.
Both AI-powered and non-AI-powered EHR platforms automate your processes for greater efficiency. These programs tackle tasks such as patient intake, registration, and initial assessments. You can move your patients through the intake process more quickly to provide more efficient care.
Automation also helps you process claims more accurately. EHR systems that work with your claims and billing software can match patient data with codes and flag errors. You can fix these errors before submitting the claim to reduce denials and improve your cash flow. These systems also autofill parts of your patients’ charts, allowing your administrative team to process more claims.
Telehealth makes care more accessible to patients. If your patient has mobility issues or lives in a rural area, telehealth lets you manage their care without burdening them with frequent trips to your facilities. Wearable devices help you monitor vital signs and notify your patients when they need to come in for a follow-up. This technology allows more of your patients to rehabilitate at home instead of staying in your facility full-time.
Policy and Reimbursement Trends Supporting Technology Adoption
Healthcare regulations don’t always move at the speed of technology. Although AI-powered devices can vastly improve your ability to care for patients, regulations and reimbursement rules haven’t caught up. The FDA needs to clear devices before CMS will agree to reimburse you for treatment.
However, regulatory agencies are getting on board as CMS and other insurance agencies shift to a value-based model for reimbursement model. These organizations and agencies, such as the Veterans Health Administration (VHA), recognize the critical role technology plays in improving patient care and contributing to patient well-being. Some of these agencies are participating in think tanks and other developmental groups to influence new healthcare technology.
Conclusion and Key Takeaways
Incorporating the latest tech can help you improve patient outcomes and reduce readmissions for LTPAC patients. Your patients benefit from personalized care based on their individual cases. Since you can access and monitor more data, you better understand how much care a patient will need to recover.
Find an EHR system that integrates with your other technology and that of other patient care team members. Adopt emerging technologies, such as AI and telehealth, to track patient vitals and care for patients without seeing them in person.
Actionable Steps For LTPAC Providers To Implement Technology-Driven Solutions
Before jumping on the latest tech trends at your LTPAC facility, outline a vision and goals for your new platforms. Then, audit your existing software to identify gaps and ways to fill them with emerging technology.
Include members of your staff in the goal-setting process. Ask them how they’re using current technology and any needs they might have for a new system. Bringing your staff on board in the planning process helps mitigate resistance to change and encourages buy-in. Instead of worrying about how new technology will impact their roles, your team will be engaged and excited to work with the new system.
Once you’ve defined your goals, start comparing vendors to find the best solution for you. Consider your budget and the number of users on your platform. Look for solutions that fit within your budget while offering your desired features. Make a list of all the systems you use regularly to ensure your new platforms integrate with them.
When you’ve chosen the right platform, coordinate with your vendor to train your staff. Some vendors offer training and support, while others may offer materials and other resources. Start small with your advanced staff so they can identify software tricks and identify pain points within the software. Some processes will likely be more intuitive than others. Your tech-savvy team members can then train the remaining staff members and assist when issues arise.
Phasing your implementation process also helps you maintain normal operations throughout the training process. Throughout the implementation process, get feedback from your team. Foster a culture of continuous learning so your team is more open to working with new technologies. That way you can upgrade more of your systems without shocking your employees.
The Role of ChartPath in Supporting Providers with Integrated, Data-Driven EHR Solutions
ChartPath by LivTech offers innovative technology solutions to transform your LTPAC agency. We understand how technology makes your work life more manageable and enables you to focus on patient care. Our streamlined charting solutions help you coordinate care across multiple specialties for a 360-degree view of each patient. Treatment notes are automatically sent to facilities and billing in real time.
Our solutions integrate with a variety of charting, compliance, and care management tools explicitly geared toward post-acute care, allowing you to access all the tools you need without switching between systems.
Readmissions for LTPAC patients are greatly reduced when you incorporate technology. New technological developments, such as AI, remote health, and EHR solutions, help you work with your patients to personalize a healthcare plan that promotes rehabilitation. Learn more about how we can empower your agency to transform your care through tech. Contact us today.
Citations
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