the hospital inefficient use of resources hospital time and beds are used on patients who could’ve avoided readmission superfluous costs two thirds of readmissions are avoidable ($7k per readmission) indicator of poor quality Medicare uses readmission rates to rank the quality of care in hospitals 2
now aligned payers providers patients hospitals are now fined for readmissions under Medicare patients want to stay out of hospitals insurance companies want to save money 3
non-adherence poor information transfer poor monitoring adherence through education and monitoring by patients’ caregivers (family and friends) ? ! ! ! 5
meds! let’s carpool to work! reminds Bob to take his meds records Bob’s vital signs teaches him post-discharge best practices Bob is a CABG patient. drives Bob to work every morning Varun is Bob’s best friend. Laura is Bob’s wife. Andy is Bob’s son. takes Bob to walk for his exercise regimen Boo is Bob’s dog. keeps Bob happy 7
but are often overlooked. their focus our focus community simplifying hospital discharge protocols facilitating transfer of discharge summaries teaching patients protocols pre-discharge 8
around one patient task delegation tasks for recovery and patient monitoring can be delegated to each caregiver in the network monitoring active monitoring by caregiver is more accurate and consistent than self-reporting predictive evaluation be able to distinguish events that may indicate a deleterious change in the patient’s health status 10
designed by Lemon Liu from The Noun Project Hospital designed by Eduardo Souza from The Noun Project Smartphone designed by George Agpoon from The Noun Project Dog designed by Markandeya Sendan from The Noun Project 87.3% of all readmits are CABG related : Hannan EL, Zhong Y, Lahey SJ, et al. 30-Day Readmissions After Coronary Artery Bypass Graft Surgery in New York State. J Am Coll Cardiol Intv. 2011;4(5):569-576. doi: 10.1016/j.jcin.2011.01.010. 500,000 CABG surgeries performed per year: http://med.umich.edu/cardiac-surgery/patient/adult/ adultcandt/cabg.shtml Average cost of CABG: Birkmeyer JD, Gust C, et al. Medicare Payments for Common Inpatient Procedures: Implications for Episode-Based Payment Bundling. Health Services Research. 2010; 45(6 Pt 1): 1783–1795. doi: 10.1111/j.1475-6773.2010.01150.x Attribution