Readmission Reduction

Reduce Readmissions with Care Guidance

Readmissions happen—not because of shortcomings with your physicians or nursing staff—they happen because the gaps that drive readmissions occur in the community, outside of your visibility, care, and connection to the patient. In a recent Guideway Care analysis of close to ~1000 navigated patients, the two biggest drivers behind readmissions were scheduling follow-up appointments and medication adherence, both of which were heavily influenced by transportation needs and financial challenges. There is no way for your clinicians to find every gap for every patient AND engage the resources needed to fill the practical, emotional, and financial barriers that bring patients back to the hospital—not at scale and not cost-effectively.

Our approach to readmissions is based on salutogenesis—a holistic approach to patient wellbeing that is the opposite of mere patient engagement. Readmissions are affected by more than just access to food, transportation, and medications. Guideway Care works to find and solve the countless issues embedded in the social determinants of health, and our interactions can include PHQ screenings, identification of psychosocial issues, and coordination and communication with a patient’s care network. The typical return on investment is between 3-6x depending on the population, rate of readmissions, and type of readmission targeted.

Why Care Guidance Works against Readmissions

HCAHPS Scores
Guideway Care supports and extends your care team, reaching your patients beyond the facility walls to improve their experiences and outcomes, reducing clinical strain and burnout, and reducing or eliminating your current readmission penalties.
Building an effective, economically feasible guidance program that bridges the gaps patients experience in their care journey has proven difficult for many hospitals. In addition, traditional patient navigation models that use costly clinical resources and technology platforms have failed to drive patient behavioral change and uncover and address the barriers hidden within social determinants of health. As readmission rates stagnate or even rise and opportunities to improve patient satisfaction are superseded by competing priorities, hospitals are burdened with rising readmission penalties under the HRRP and are falling further and further behind in preparing for other looming value-based reimbursement requirements.
Guideway Care offers a proven, technology-enabled care guidance program that integrates with your current care team and unifies patient data from across the system, allowing you to quickly and efficiently extend individualized, disease-specific support to patients outside facility walls. The gains made in the areas of care transitions, collaboration, and knowledge gaps will lead to rapid improvements in patient outcomes and satisfaction, as well as readmission rates.

Average Hospital
Readmission Penalties

as a reduction of Medicare payments for inpatient admissions per financial year
Data from the Kaiser Family Foundation

Disease-Specific,
Tailored Programs

Guideway offers care guidance programs tailored for each of the conditions/disease states covered under HRRP, with effective, evidence-based protocols for AMI, CABG, COPD, Heart Failure, Pneumonia, and THA/TKA.
In fact, out of the 47 top readmission factors for these conditions combined, Guideway’s program can directly impact 34 factors with non-clinical interventions. Guideway Care’s care guidance services are the lever your organization needs to reduce or remove your readmission penalties.