Reducing Readmissions Using IT

Supported by mobile technology, trained health coaches at the Elder Services of Merrimack Valley in Northeastern Massachusetts ( recently visited discharged Medicare patients in their homes as part of a new innovative trial involving 561 frail senior adult patients ages 65 to 79.

Many hospitals are trying to reduce readmissions by changing discharge procedures and improving transitions across care settings. However, these efforts generally focus on making changes within the institutional setting and may not adequately address community factors such as access to primary care or the lack of support at home.

The trial program started with community-based health coaches and care coordinators going to visit patients in homes using technology to support the home visits. In addition, monitoring by telephone was available over a four week period.

Aided by tablet-based software developed by “Care at Hand,, a community-based care transition program, health coaches were able to conduct in-home visits. The health coach uses the software application to ask questions designed to detect a decline in health status that might increase the risk for readmission to the hospital.

Based on the initial screening, diagnosis, the patient’s living situation, and answers to previous questions, the software suggests 10 to 15 questions that are appropriate for the health coach to ask. If the patient has more than one diagnosis, the software prioritizes the questions to ask concerning the most recent diagnosis and/or those conditions that are most likely to lead to readmission.

If a health problem is indicated, the system automatically generates an alert categorized as mild, moderate, and high depending on the urgency. The alert is sent to a nurse care coordinator. During the first six months of the program 22 percent of the 1,902 questions administered to patients triggered an alert.

After receiving the alert, the nurse care coordinator can access the system with a computer or smart phone through a separate portal using higher level clinical language and also features additional support related to patient follow-up and monitoring.

The software-based system documents all care coordination activities, including the questions asked, then care coordinators are able to use the information to provide ongoing feedback to the health coaches on their performance.

The trial found, that the use of health coaches supported by the tablet-based software significantly reduced readmission rates for 30 day readmissions by 39.6 percent among at-risk patients. The decline in readmissions generated substantial cost savings averaging $109 per patient per month with gross savings of roughly $600,000 and net savings of about $370,000 during the six month trial period.

The costs of the program during the six month evaluation period totaled roughly $205,000. The technology part of the program cost $30,500 including software, tablets, data connections, and training.

The Center for Medicare and Medicaid Innovation provided the funding that currently covers program costs only. Elder Services of Merrimack paid for the “Care at Hand” technology, tablets, data connections, and staff technology training from their general operating budget. In addition, several area payers reimbursed Elder Services for care coordination services provided to patients who are dually eligible for Medicare and Medicaid.

The snapshot summary for the trial project is available on AHRQ’s Innovations Exchange web site at

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