Readmission Case Study

The effects of readmissions on population health
Impact of readmission from SNF on population health can be estimated in various categories and perspectives. There can be especially negative impact and possible burden for our community to have avoidable or unnecessary readmissions, although some of readmissions are inevitable and planned.

The major categories of the impact are population health outcome, such as death, disability, morbidity and quality of life, and economical measure, such as primary health care cost and other sectors such as cost for family/care giver, lost income, lost tax revenue and products, can be estimated as a means of measurement of impact of readmission on population health.
The root of problem
Financial
What

(Kripalani et al., 2014)

Historically, fee for service model of insurance in US has put great pressure on shortening acute-care hospital stay and preventing readmission had no incentive for the acute hospital in the past. There were limited public or insurance measurements in terms of readmission, quality of transition, and overall outcome of patient’s health care.

First, there have been more financial incentives for acute-care hospital side, such as Medicare readmission reduction program and penalty, also more bundled payment and shared saving models, which can be the more financial incentive and potential penalty for acute-care hospital and SNF.

Another incentive is from being participating on ACOs, which “require comprehensive and integrated data and analytic systems that provide meaningful population data to inform care teams in real time, promote quality improvement, and monitor spending trends.” (Berkowitz & Pahira,

(Lindenauer et al., 2007)

However, this has produced multiple hand-offs due to involvement of multiple providers via not fully or partially interoperable or inter-communicable information and communication technology (ICT) and system. (Spehar et al., 2005)

In terms communication, in fact, there were many SNF that still uses fax and paper chart to document and communicate with other organization and delayed full implementation of EHR or ICT due to the limited capital and the hardware/infrastructure for implementation. (Filipova, 2013)

These trends may have accelerated the further fragmentation of health care delivery and challenging transition and coordination of care.
Inconsistency in transition in care
Third, There are inconsistency in transition in care and limited universality across the practices of each health care