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Development and Evolution of a Best-Practice Hospital-Based Care Transitions Program
This case study outlines how Healthways can help avoid hospital readmissions and improve patient care.
Executive Summary
Despite the overwhelming evidence that readmissions are often preventable and consume a significant portion of Medicare spending, there has yet to be a widely applicable solution to preventing them that is both cost effective and efficient. In fact, a recently published study at Baylor Medical Center in Garland found they could reduce 30-day readmission in Heart Failure (HF) by 48%, but they lost an average of $751 in revenue on each patient. The average cost of providing the intervention to each CHF patient was $1,100.1
Healthways has a history of addressing the problem of preventable readmissions. In fact, for over 15 years, Healthways has administered a Hospital Discharge Campaign for several large clients. That campaign has proven to be quite successful – achieving a 23.1% percentage reduction in hospital readmissions compared to the non-intervention group.2
Yet, Healthways leadership has been fundamentally convinced that a greater reduction could be achieved if resources were invested sooner with the patient and further upstream in the process. Until recent health care reform legislation there was little incentive to test that belief. As incentives for our clients have aligned, we have invested significant resources scouring the evidence for effective interventions, and designing a solution that executes “best-practice” interventions to a heterogeneous population in a cost-effective way from admission to 30 days post-discharge. After a year in the making, the solution was piloted at Southwest General Hospital in San Antonio, Texas in self-pay patients.
The solution design proved to be overwhelmingly effective. Results from the Care Transitions (CTS) pilot revealed a 44% reduction in self-pay readmissions when compared to the same period in the prior year. Download the whitepaper.
1 Stauffer, Brett D. MD, MHS et. al. Effectiveness and Cost of a Transitional Care Program for Heart Failure. Arch Intern Med. 2011;171(14):1227.
2 Harrison, Patricia L, MPH, et. al. The Impact of Post-discharge Telephonic Follow-Up on Hospital Readmissions. Population Health Management, Volume 14, Number 1, 2011.
