Want to create your own safety net? Check out these ready-to-use readmission root cause evaluations

But when we share this concept around the world, we are often met with questions that stem from concern and fear. 'What happens if we graduate a patient who seems to be in control, but they later slip up?' or 'If we don’t have frequent touchpoints with them, how will we know or be able to help if things go awry?'

Patient Activation Measure: An emerging tool for patient self-management

These are valid questions, and it's true that despite our best efforts, factors outside of anyone’s control can knock even the most successful self-managers off course.

How two organisations 'catch' their patients

The best care management programmes acknowledge and proactively prepare for this reality, allowing them to set up fail-safe systems to ‘catch’ patients when they fall. Let’s take a look at two organisations that have done just that.

1. South Simcoe and Northern York Region (SSNYR) Health Link, Ontario, Canada

SSNYR is an Ontarian Health Link, i.e., a team of providers in a geographic area delivering coordinated care to the province’s costliest patients with multiple complex conditions.

SSNYR Health Link had success with helping patients become stronger self-managers and gradually stepping down their support—but they still had the frustrating experience of some of these patients later turning up at the hospital.

In response, the team developed a system to flag patient lapses and ensure quick intervention. At enrolment, each Health Link patient is tagged in the local hospital's EMR. A hospital visit triggers a notification to Health Link staff, who reach out to the patient to determine the reason for the admission.

A group of clinical and non-clinical partners meet once a month to discuss these patients and identify additional support resources to address the root cause of the readmission. Usually this is enough to get the patient back on track.

However, if a patient readmits multiple times, or the meeting with the patient raises significant concerns, SSNYR Health Link has another back up: a higher tier meeting to discuss patient cases. This group includes an even broader array of non-clinical partners, including the police, and meets twice per week to ensure fast intervention.

The right route to avoid 3 pitfalls of chronic disease management

2. Western HealthLinks, Victoria, Australia

Health system Western Health partners with Silver Chain Group to deliver home-based care for high-risk patients in their Western HealthLinks programme (like Ontario, Victoria has a high-risk patient programme called HealthLinks).

Enrolled patients are stratified into high-, medium-, and low-risk care groups based on their risk of readmission. A patient in the high-risk group will receive weekly home visits, intense care coordination support, and access to a 24/7 support number, while a patient in the low-risk group will receive only an initial home visit and access to the support line. Over time, patients transition to lower risk groups as their self-management abilities improve—this serves as Western HealthLinks' 'graduation' function.

However, if a patient readmits to the hospital at any time—regardless of their care group—it triggers an EMR alert. The HealthLinks team then visits the patient while still in hospital to identify any necessary changes to their care plan. Further, they're automatically escalated to the high-risk care group to receive more intense support until they're ready to transition back to the medium- or low-risk group.

How to create your own safety net

The SSNYR Health Link and Western HealthLinks approaches have four core elements in common; take note as you develop your own fail-safe systems:

1. Set up a mechanism to quickly flag patient readmissions. The EMR is often the simplest tool, but it’s possible to do this work manually if the technology isn't available.
   
   
2. Identify the root causes of readmission in a timely manner. Training staff on a standard protocol to reach out to patients allows them to ask key questions to assess the reason for the readmission.
   
   
3. Pick the right partners to provide follow up support. Relationships with community and non-clinical partners make it easier to provide coordinated support to address underlying needs.
   
   
4. Establish a process to transition patients back to self-management. While it's tempting to continually support these patients, it's important to step down support once the patient is back on track—trusting that the backup system will do its job again if needed.

Together, these components can provide the reassurance that graduating our patients doesn't mean we're kicking them out forever. Rather, we're letting them support themselves until they need us again, if that need arises.

New infographic: Graduate high-risk patients to self-management

Learn how to design a high-risk patient programme that ultimately 'graduates' patients to self-management.

Download Now