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

Helping patients transition from hospital to home is a major challenge that requires providing individual attention for each patient after they leave the hospital, and Hensen stresses that the technology could not work without the patient engagement aspect. “That is the vital part to this,” he says. “When a hospital releases a patient and is blind to what is going on with him/her, the patient may not understand the discharge and the hospital may never know if the patient is taking the required medications. You only know their status and condition when they’re NOT doing well, and that’s not the goal. We think the notion of having this health check on a daily basis will give us a big jump on things before there is an emergency or before there’s something that would cause a readmission.” Hensen warns that while all readmissions cannot be prevented, “there is a lot of hard and anecdotal information that we’ll get before that patient is really symptomatic of being ready to come back to the hospital.”

And while Hensen wouldn’t get too specific with numbers, he says that Vree expects to reduce the amount of avoidable readmissions to meet the requirements of the [mandatory] the Centers for Medicare & Medicaid Services (CMS) Readmissions Reduction program. “Our goal is to be above 20 percent reduction [with TransitionAdvantage]. That’s not a promise, just a design goal, and in reality, we want to be even higher than that.”

Hensen says that Vree’s readmissions design essentially operates on a four-area approach: filling in the gaps, monitoring follow up, improving medication, and care coordination. That’s not the end all be all though, he says. “When we come in and do the consulting, we’re not consulting on how to do readmissions or follow up, but instead we’re looking at hospitals’ goals and the program they are following, so we can show them how to integrate multiple services to support that program. Trust me, the last thing a hospital needs is another major project. But we tell hospitals, it’s not just technology, it’s the integration of these different services, and it’s not a lot of weight on your shoulders.”