CMS Reinforces the Importance of Post-Hospital Discharge Outreach

The Centers for Medicare & Medicaid Services (CMS) proposed to revise the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs. The proposed changes would modernize the discharge planning requirements by: bringing them into closer alignment with current practice; helping to improve patient quality of care and outcomes; and reducing avoidable complications, adverse events, and readmissions.

Eliza’s multi-channel solutions help health plans, hospitals, provider groups, pharmacy benefit managers and home health agencies improve member engagement and quality scores in all areas of care, including medication adherence, chronic condition management, and ED and hospital readmission reduction. Our Post-Hospital Discharge solution is a great way to ensure compliance with the proposed post-discharge follow-up process. In fact, the proposed rule states, “Post-discharge telephone call programs can improve patient safety and patient satisfaction, and may decrease the likelihood of post-discharge adverse events and hospital readmission. Post-discharge follow-up can help ensure that patients comprehend and adhere to their discharge instructions and medication regimens. Furthermore, post-discharge follow-up may identify problems in initiating follow-up care and detect complications of recovery early, resulting in early intervention, improved outcomes, and reduced re-hospitalization.” We couldn’t agree more. Eliza's Post-Hospital discharge solution reduces readmissions by quickly following up with members and assessing and addressing the most common drivers of readmission – whether they fully understand the discharge instructions, whether they’re following the prescribed medications, and whether they’ve scheduled an appointment with a clinician. We also have the ability to collect other interesting tidbits. For example, during a recent Eliza Post-Hospital Discharge program, we learned that of the 8,000 people Eliza engaged:

  • more than 10% (812 people) said they didn’t have anyone to take care of them after being discharged from the hospital
  • 7% (600 people) said they had urgent concerns about their health
  • 3% (214 people) said they did not understand their discharge instructions

These are the people that are at the greatest risk for readmission. Giving clients valuable and actionable feedback enables them to educate patients on self-care, address their health concerns, and provide resources to reduce barriers to care.

“This rule puts the patient and their caregivers at the center of care delivery,” said CMS Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., MSc. “Patients will receive discharge instructions, based on their goals and preferences, that clearly communicate what medications and other follow-up is needed after discharge, and pertinent medical information will be communicated to providers who care for the patient after discharge. This leads to better care, smarter spending, and healthier people.”

Overall, at Eliza, we know that engagement strategies designed to make a human connection based on an understanding of individuals as whole people in time – not just as temporary patients – have the greatest impact – and as a result, offer the best health, care and financial outcomes for individuals and the healthcare providers that serve them.

To request more information on Eliza’s Post-Hospital Discharge solution, please click here.  



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