Accountable Care Organizations (ACOs) track 30-day readmissions using a combination of data analytics, electronic health records (EHRs), and care coordination strategies. Here’s how they typically do it:
1. Electronic Health Records (EHRS)
- Automated Alerts: EHR systems can be configured to flag patients who are readmitted within 30 days of discharge. These alerts help care teams quickly identify patients who may be at risk of frequent hospitalizations.
- Data Collection: EHRs collect detailed information about patient care, including discharge dates and readmission occurrences. This data is used to track readmission rates over time.
2. Care Coordination After Discharge
- Post-Discharge Follow-Up: ACOs often implement follow-up procedures after a patient is discharged, including phone calls, home visits, or outpatient appointments. These efforts help ensure that patients are adhering to their care plans and addressing any issues that could lead to readmission.
- Patient Education: Educating patients about their conditions and care plans, including medication management and symptom monitoring, helps reduce the likelihood of readmission.
3. Performance Metrics And Analytics
- Performance Metrics: ACOs use analytics tools to monitor readmission rates as part of their performance metrics. These tools can identify trends and patterns, such as which patient populations are most at risk for readmission.
- Predictive Analytics: Some ACOs use predictive modeling to identify patients at high risk of readmission. This allows them to target interventions more effectively to prevent readmissions before they occur.
4. Collaboration And Information Sharing
- Information Sharing: ACOs work closely with hospitals and other healthcare providers to share information about patients who have been discharged. This collaboration ensures that all providers involved in a patient’s care are aware of the potential risks and can take appropriate actions to prevent readmissions.
- Discharge Planning:
Effective discharge planning, including clear communication of follow-up care instructions, helps reduce the risk of readmission.
5. Patient Engagement
- Monitoring and Support: ACOs often provide patients with tools and resources to monitor their own health, such as mobile apps, wearable devices, or remote monitoring systems. This helps patients stay engaged with their care and seek help before a condition worsens to the point of requiring readmission.
- Data Submission: ACOs are required to report their readmission rates to the Centers for Medicare & Medicaid Services (CMS). CMS uses this data to evaluate the performance of ACOs under the Medicare Shared Savings Program (MSSP) and other value-based care initiatives.
By closely monitoring 30-day readmission rates, ACOs can identify areas for improvement in patient care, reduce unnecessary hospitalizations, and achieve better health outcomes while lowering costs.
Lisa Remington
Lisa is a home care and health care growth and business development strategist. As president of the Home Care Leadership Think Tank and publisher of The Remington Report, she is well-known as a trusted industry advisor aligning strategic market intelligence into actionable strategies and business blueprints for decades. Lisa has led C-suite education to over 10,000 organizations through a variety of platforms, including think tanks, strategic improvement programs, board retreats, executive leadership programs, peer-to-peer networking groups, and advisory services.
