How can you reduce readmissions through utilization management?

Readmissions are costly and detrimental to patient outcomes, but they can be prevented or reduced by effective utilization management. Utilization management is the process of ensuring that patients receive appropriate and efficient care that meets their needs and goals. In this article, we will explore how you can use utilization management strategies to reduce readmissions in your case management practice.

1 Assess patient risk

The first step to reducing readmissions is to identify and stratify patients who are at high risk of returning to the hospital. You can use various tools and criteria, such as the LACE index, the HOSPITAL score, or the CMS readmission measures, to assess patient risk factors, such as length of stay, comorbidities, prior admissions, and discharge disposition. By assessing patient risk, you can prioritize and allocate your resources and interventions to the most vulnerable patients.

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Fardin Quazi

Digital Business Transformation Expert in Healthcare | Intuitive Ops & Automation | Digital Technology Business Solution & Implementation | Health Tech Solution | Medicare & Medicaid | Robotics Process Automation & AI
Here is a new term which is gaining prominence, which is very effective in reducing post operative readmission rate - " Discharge Planning & Management" Discharge Planning is associated with multiple aspects such as Transitional Care, Medication support & reconciliation, Hospice and patient education. All these aspects planned and implemented in a streamlined manner would create a customized discharge planning an post -acute care process for the patient to recuperate and recover in a rehab facility or a home health service setup. Leveraging AI to create a discharge plan for the patient integrated with Telehealth & Telemedicine support services would ensure that UM of all services are implemented successfully to reduce readmission.
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2 Coordinate care transitions

The second step to reducing readmissions is to ensure smooth and safe care transitions from the hospital to the next level of care, whether it is home, skilled nursing facility, or other setting. You can coordinate care transitions by communicating effectively with the patient, the family, and the interdisciplinary team, by providing clear and timely discharge instructions and education, by arranging follow-up appointments and referrals, and by reconciling medications and equipment. By coordinating care transitions, you can avoid gaps and errors in care that could lead to complications and readmissions.

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Adrienne Maye

RN, BSN, CDCES; CEO at Moving Forward with Diabetes Management Author📙, Featured Speaker at ADCES22 🎤, Guest Speaker on Health Unmuted Preventing Type 2 Diabetes Podcast 🎙
Coordination of care for a successful transition from hospital to home requires the assistance of everyone involved in the patient's care from the inpatient and outpatient care team. Unfortunately, not every care setting has an outpatient case management team that includes Registered Nurses, Social Workers, Pharmacists, Health Coaches and other team members that work cohesively together for safe and efficient outcomes. When you have a team of dedicated team members working together to achieve safe discharges and assisting patients to address care gaps such as medication reconciliation, DME ordering and making sure outpatient follow up appointment are scheduled within a timely manner. This provides a positive effect on reducing admissions.
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3 Monitor patient status

The third step to reducing readmissions is to monitor and evaluate patient status and progress after discharge. You can monitor patient status by conducting phone calls, home visits, or telehealth sessions, by reviewing clinical data and reports, and by soliciting feedback from the patient, the family, and the providers. By monitoring patient status, you can identify and address any issues or concerns that may arise, such as symptoms, medication adherence, social support, or access to care.

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4 Implement interventions

The fourth step to reducing readmissions is to implement evidence-based and patient-centered interventions that address the patient's needs and goals. You can implement interventions by providing case management services, such as care planning, advocacy, education, counseling, and coordination, by facilitating self-management and empowerment, by linking the patient to community resources and support programs, and by collaborating with the patient's primary care provider and other specialists. By implementing interventions, you can enhance patient satisfaction and quality of life, as well as improve clinical outcomes and reduce costs.

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5 Evaluate outcomes

The fifth step to reducing readmissions is to evaluate the outcomes and impact of your utilization management efforts. You can evaluate outcomes by measuring and analyzing key indicators, such as readmission rates, length of stay, patient satisfaction, quality of care, and cost savings, by comparing your results with benchmarks and best practices, and by soliciting feedback from stakeholders and partners. By evaluating outcomes, you can identify and celebrate your successes, as well as identify and address your challenges and opportunities for improvement.

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6 Learn and improve

The sixth and final step to reducing readmissions is to learn from your experiences and continuously improve your utilization management skills and processes. You can learn and improve by engaging in professional development and education, by participating in quality improvement initiatives and research, by sharing your knowledge and best practices with your peers and colleagues, and by adapting to changes and innovations in the health care system. By learning and improving, you can stay current and competent in your case management practice, as well as contribute to the advancement of your profession and the health of your patients.

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7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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Daniel Carey

Senior VP, Healthcare Quality
Part of utilization management is not only knowing when and how people are being served but also knowing when they are not being served. Transitions in care are some of the most dangerous in terms of patients falling through the cracks or falling back into dangerous behaviors because they are not being adequately served. Instead of “pushing” the patient out in a discharge process and hoping they make it to their next appointment, we need to “pull” the patient into services at the next level by coaching the patient and remaining active in that transition. Patients often need help overcoming the barriers that lead to readmission. We have a role in the patient’s success.
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How can you reduce readmissions through utilization management?

1

2

3

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5

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1 Assess patient risk

2 Coordinate care transitions

3 Monitor patient status

4 Implement interventions

5 Evaluate outcomes

6 Learn and improve

7 Here’s what else to consider

Case Management

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How can you reduce readmissions through utilization management?

1

2

3

4

5

6

7

1 Assess patient risk

2 Coordinate care transitions

3 Monitor patient status

4 Implement interventions

5 Evaluate outcomes

6 Learn and improve

7 Here’s what else to consider

Case Management

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