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From Hospital to Home: A Service to Reduce Readmissions Built Around Engaging Patients

June 28, 2013
by Rajiv Leventhal
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As hospitals face increased pressure to reduce readmission rates, one consulting company might have found an answer
Dyke Hensen

Readmissions continue to be a significant concern for hospitals, as they will receive cuts to their Medicare payments for higher-than-expected readmission rates for certain diagnoses.

Last year, Medicare began levying financial penalties against hospitals with avoidable readmissions under a mandate from the Affordable Care Act.  And although federal officials say that readmission rates have dropped, repeat hospitalizations can still be avoided far more frequently. While many readmissions are not avoidable, others are the result of gaps in care management, particularly in post-discharge follow up.

To this end, Vree Health LLC, a North Wales, Pa.-based subsidiary of Merck Sharp & Dohme Corp., based in Whitehouse Station, N.J., and a consultant in helping redesign processes surrounding readmissions, offers TransitionAdvantage, a post-discharge service designed to help hospitals reduce preventable 30-day patient readmissions. By engaging patients on a daily basis and improving coordination across care providers, TransitionAdvantage is designed to help patients adhere to the hospital’s recommended post-discharge care plan. 

The service is on the verge of being implemented in Griffin Hospital, a 160-bed acute care community hospital based in Derby, Conn., and Vree has also partnered with Frontier Medicine Better Health Partnership (FMBHP), a Montana-based partnership and learning collaborative.

The core of the TransitionAdvantage service is a scalable, flexible, cloud-based electronic patient profile, seamlessly populated initially by an electronic medical record (EMR), and updated throughout the 30-day post-discharge period with patient health information. The system integrates and aligns with the hospital’s current processes and technologies to extend its reach and provide connectivity across the entire care team.


The solution, says Dyke Hensen, senior vice president at Vree Health, combines an innovative data sharing and care coordination platform with the individual attention of a Transition Liaison, who helps reinforce patient compliance with their prescribed care plan. Furthermore, powerful technology provides relevant and timely data to enhance the quality improvement processes.

“We’re trying to fill in a lot of gaps that happen when someone leaves the hospital,” Hensen says. “We want to put in place a formal follow-up system and share that to the extended caregiver network as well as tying in the primary care providers and the information back to the hospital. It really is about care coordination and hopefully some positive behavioral change with a lower cost approach.”

This is how the process works, explains Hensen: “When a patient is sitting in the hospital, about to be released, one of Vree’s people will go through a preliminary health check [with him or her]. What we have in the background is a care plan that was developed with the help of Merck’s medical staff and it walks through a set of check points, both hard data and soft data. This includes things like blood pressure, weight, dizziness, and energy level. It’s about a 5-7 minute checkup, which could happen in a couple of different modes:  through an outbound call; on the web; or via a voice service.  This service lasts from 14-30 days.”

And nurses and physicians get the summary reports on a dashboard setup. It’s designed to be an easily consumed interface—not like looking at an EMR system. It’s a web-based set of screens and it’s not onerous, Hensen says.

Vree recommends in its service that the checkups happen every day, but there are hospitals that suggest every other day is more preferable, so whatever the hospital’s follow-up plan of care is, Vree adapts the system to accommodate it, Hensen says. “We’re making an abbreviated patient profile—a combination of pertinent EMR data along with our interactions with the patient. And this is all connected in real time online. So if an alert in the system goes off signaling a change in health status, a Transition Liaison will immediately make a call.” Vree’s call center has been trained in behavioral and motivational communications, says Hensen, adding that motivational techniques will often help patients, and the Liaison will eventually determine if the situation needs to be escalated to the nurse line or hospital.

While Vree has been working on the TransitionAdvantage design for more than two years, the design criteria have changed a little, Hensen says. “When first designed, it was all about everything we could do to reduce readmissions. And that’s still the main goal, but what we have learned over time is more of an emphasis on sharing data, and collaboration with other care networks. As we have worked with the product, it’s not just about filling the gaps when a patient leaves a hospital to when they come back, but the gaps that happen after that, too. Are they going to a nursing facility or back home? Do we need to extend a user interface to a caregiver if it’s a spouse or child? These are questions we needed think about during design.”