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Long-term and post-acute care's roles in lowering hospital readmissions

December 10, 2013
by Lois A. Bowers, Senior Editor
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Certain post-acute medication management interventions can help reduce hospital readmissions, according to research by Purdue University, home healthcare and hospice care company Amedisys Inc. and specialty pharmacy HealthStatRx.

“Just as we hypothesized, post-acute care interventions can make a positive impact on preventing issues the elderly may have with their complicated medication regimes, ultimately resulting in lower readmissions,” says Julie Lewis Sutherland, vice president of research and development for Amedisys.

Members of the intervention group in the study were eight percent less likely to be readmitted to the hospital compared with members of a control group. The interventions:

  • Those studied were stratified according to risk, and the probability of hospitalization during the home health episode of care was modeled.
  • A pharmacist reviewed patient charts for any possible triggers, and the pharmacist proactively notified the home health care team, including the physician and home health caregivers, he or she identified any issues.
  • The pharmacist directly engaged sick individuals via a phone call immediately after they were admitted to home health to educate them on the evaluation of their medication(s). Also, the pharmacists conducted follow-up calls directly with sick individuals between day seven and day 30.
  • The pharmacist, physician, sick individual and home health care team collaborated to resolve any identified problems.


Other research by HealthLeaders Media Intelligence Unit in collaboration with Amedisys found that 64 percent of senior hospital leaders are lowering preventable readmissions by partnering with long-term care and skilled nursing facilities.

Other strategies:

  • Partnering with home healthcare (73 percent);
  • Scheduling follow-up visits with primary physicians (69 percent);
  • Adjusting clinical protocols and discharge practices during acute care (62 percent);
  • Providing a hospital-to-home care transition program (56 percent);
  • Providing care navigators/coaches for high risk patients (56 percent);

The survey polled 106 senior leaders, including CEOs and physicians, at 75 hospitals and health systems nationwide.

“Managing chronic disease should involve post-acute care, complete with frequent monitoring of vital criteria, including blood pressure, diet and physical activity,” says Michael Fleming, MD, FAAFP, and chief medical officer for Amedisys. “Hospitals are seeing the benefit of collaborating with post-acute care partners in an effort to improve their patients’ health and prevent hospital readmissions because we can deliver such regular oversight, including strategies such as patient education before discharge, medication management and primary care physician follow-up.”

See other content by this author here.