Images captured by Elliott Cramer of agilon health employees for their campaign Healthcare Reimagined.  Images created in Naples, Florida during a doctor retreat.  Image of Doctor Stephen Buksh of Catalyst Health Group - Dallas, TX with models Catherine and Charlie Kelly.

Blog | Feb 07, 2024

3 Strategies to Reduce Hospital Readmissions for Older Adults and Senior Patients

Hospital readmissions can be particularly challenging for seniors and patients, making it a critical area of focus for both providers and payors. This issue has been at the forefront of healthcare reforms for over a decade, with the Affordable Care Act (ACA) of 2012 introducing the Hospital Readmission Reduction Program to encourage hospitals to reduce these occurrences. A hospital readmission, typically defined as a patient returning to the hospital within 30 days of discharge, not only impacts patient well-being but also reflects on the quality and cost-effectiveness of healthcare services.

In this post, we’ll look at strategies, tools, and methods designed to prevent readmissions for older adults, integrating these approaches into the broader context of value-based care. By addressing this challenge, providers can significantly enhance health care outcomes for senior patients, while also advancing the overall efficiency of the healthcare system.

Why Is Reducing Hospital Readmissions Important?

Reducing hospital readmissions is important for several reasons, chief among them being that readmissions can negatively affect quality of care and patient satisfaction. They can also be associated with significant costs for hospitals, patients, and payors. According to recent data,  up to 27% of readmissions could be prevented with improved communication between health care providers and their patients. Leveraging health data from electronic health records (EHRs) and health information exchanges (HIEs) provides valuable insights into the patterns and catalysts behind readmissions.

Armed with this knowledge, providers can develop and implement targeted strategies to effectively reduce the risk of readmission, ensuring better patient care and more efficient use of healthcare resources post-discharge.

How to Reduce Hospital Readmissions

Hospital readmissions not only present a significant challenge for healthcare systems but also have profound consequences for patient health and well-being. These readmissions often indicate gaps in care or issues in the transition from hospital to home. They can lead to increased health care costs, higher patient stress, and decreased satisfaction with care. Let’s look at three strategies for reducing the frequency of readmissions.

1. Identify Patients at High Risk for Readmission

Identifying patients at high risk for readmission following hospital discharge is a critical step in enhancing patient care and reducing unnecessary hospital visits. Various factors—such as medical diagnoses, comorbidities, emotional and personal circumstances, age, medication complexities, caregiver support, readmission history, financial challenges, and living conditions—significantly affect readmission risks. Recognizing these elements is crucial for health care providers to develop customized care plans to prevent readmissions.

agilon’s Total Care Model helps to effectively identify high-risk patients, enabling PCP’s to achieve better outcomes and reduce avoidable health care utilization. This model empowers physicians with a detailed list of high-risk patients, enhancing their ability to manage patient care proactively and to reduce the risk of readmission, ensuring timely and appropriate patient care. High-risk senior patients are flagged as potentially benefiting from earlier follow-up upon discharge to help provide continuity and better-coordinated care in what can be a challenging time for these patients.

2. Implementing Care Coordination and Seamless Care Transitions

Care coordination and seamless care transitions are pivotal in reducing hospital readmissions. Effective communication among care teams, along with comprehensive post-discharge follow-up, plays a significant role in improving patient outcomes and decreasing readmission rates. When care teams work in unison and maintain open lines of communication with patients, they can address potential health issues before they escalate. This collaborative approach ensures that all aspects of a patient’s health are considered and managed effectively. Additionally, timely and thorough post-discharge follow-ups help monitor patient progress, providing an opportunity to adjust care plans as needed and address any concerns promptly.

The partnership between Dr. Michael Morris and agilon health is an excellent example of how strategic support can enhance patient care. Through the agilon health partnership, Dr. Morris’ group established a case management team and opened an “Express Care” clinic. Operating seven days a week and after hours, this clinic has been instrumental in reducing patients’ need for expensive emergency department care. By providing high-risk patients with proactive care and managing hospital, emergency room visits, and rehab follow-up patients aggressively, Dr. Morris’ team has effectively prevented readmissions and reduced healthcare delivery costs.

Similarly, Dr. John Notaro, in collaboration with agilon health, established an extensivist clinic, akin to an enhanced urgent care center capable of administering IV medications. This clinic provides comprehensive care that would typically require an emergency room or hospital visit, thereby reducing hospital admissions.

These case studies demonstrate the profound impact of well-coordinated treatment and innovative health care models in minimizing hospital readmissions and enhancing overall patient care.

3. Enhancing Medication Management

Proper medication management is a key factor in preventing hospital readmissions, especially among older patients. Medication reconciliation is one such strategy, involving a thorough review of all medications a patient is taking to ensure there are no adverse interactions or duplications. This process is particularly important during transitions of care, such as when a patient is discharged from the hospital. Additionally, support for medication adherence is crucial. Ensuring that patients understand their medication regimens, which may have changed due to the hospitalization, and are able to follow them correctly can significantly reduce the risk of readmissions. Patient education, therefore, becomes an essential component of medication management, helping patients understand the importance of their medications and how to take them properly to manage their conditions effectively.

Dr. Natalie Williams, an agilon health partner, recognizes that this can sometimes be challenging. “Not everyone has the same level of education, and I am aware that not everyone I see will understand what I tell them”, she explains. “I don’t want my patient to misunderstand what I say and be too embarrassed to ask questions. So, it’s important to take time to explain information in the simplest terms possible so each patient understands what you’re saying.”

Preventing Rehospitalization Through Value-Based Care with agilon

The agilon Total Care Model, with its focus on personalized care and proactive health management, demonstrates a commitment to advancing patient well-being and health care efficiency. By partnering with agilon, physicians get effective tools to help reduce hospital readmission, identify high-risk patients, enhance medication management, and ensure seamless care transitions.

Learn more about agilon health and our unique partnership opportunities.


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