Practicing what we preach: Keeping readmissions low

By Mihir Patel, MD, MBA, CPE | CEO, Hospital Medicine 

A recent report from the Centers for Medicare and Medicaid Services (CMS) shows that select hospitals throughout the country are doing something exceptional: Keeping unplanned readmission rates below the national average. 

We’re honored to provide hospital-based care at 12 hospitals recognized for improving readmissions. Our teams, in partnership with these hospitals, have helped bring readmission rates below the national hospital-wide average of 14.6 percent. The data in this report was collected from July 2022 through June 2023.  

Sound’s approach to managing readmissions is focused on tried-and-true workflows led by our exceptional medical directors and teams, who collaborate with case management to identify barriers and avoidable delays. Our goal is to understand the patients’ needs once they leave the hospital and focus on helping them safely return home. 

Why do readmission rates matter? 

In hospital medicine, avoidable readmissions take a financial and emotional toll on everyone involved. For hospitals, the additional cost of care is compounded by potential penalties for too-frequent readmissions, and if already beset by capacity issues, readmissions don’t help. Clinicians who pride themselves on providing high-quality care may feel frustrated. And — most importantly — patients experience undue stress and a lack of confidence in the care they’ve received.   

Our focused approach to mitigating avoidable readmissions successfully marries our people, process, and technology for better outcomes. It’s the nexus of all three that allows us to successfully avoid the avoidable, as we were able to do with our hospital partner, helping to reduce readmissions. 

Strong teams, strong results 

Our medical directors and hospitalists engage in rigorous onboarding, training, and ongoing development, and work in close partnership with our clinical performance nurses (CPNs) — a role unique to our hospital medicine teams — to improve processes, track performance, and stay aligned on patient care. Our CPNs stay in lockstep with the medical director and hospitalists to make sure each patient is discharged successfully, and that process has been followed to prevent their readmission.  

We seek and hire clinicians committed to a high level of engagement with their team and who invest in doing what it takes to get — and keep — patients home safely. And we understand what it means to bring better care to the bedside, embracing our patient-centered approach:  

1. Transition out of the hospital as quickly and safely as possible.  
2. Enjoy a positive and holistic care experience. 
3. Avoid the avoidable.  
4. Get home.  
5. Stay home.  

With our national footprint and hyper-local focus, we take care to develop approaches that work for the specific communities we serve while also acting as a broader resource network — sharing best practices and tried-and-true solutions that can be put into action at the local level. 

In short, we build strong teams for strong results. 

We look at all the factors, in and out of the hospital 

We have dedicated processes in place to mitigate avoidable readmissions. Our CPNs are the keepers of that process, collaborating with the medical director and physicians for alignment around understanding the diagnoses and drivers that put patients at higher risk for readmissions.   

Part of our process, too, is recognizing that social determinants of health play a crucial role in whether a patient comes back to us. From housing to transportation, medication to insurance, primary care, employment, and access to nourishing food, we look across the spectrum of factors that impede recovery and healing once a patient leaves us.  

Better technology  

As a technology-enabled practice, we use our SoundConnect platform to alert teams when a patient is at risk for readmissions. These alerts are critical prompts for our team when conducting multidisciplinary rounds, as we’re able to collectively address the factors that make a patient susceptible.  

We recognize that a patient’s care extends beyond the walls of the hospital, and for those who are returning to or entering a skilled nursing facility, we partner with our telemedicine team to make the transition of care a smooth one.   

And the benefits of our technology are amplified when we’re able to integrate our emergency and hospital medicine programs for our partners. 

We want patients to safely get, and stay, home 

We’re committed to working as a team to keep our avoidable readmissions low. Our approach to patient care and hospital operations has consistently yielded a 19 percent readmissions improvement and a readmissions rate that’s 20 percent lower than national averages across our programs. Our partners let us know how much it means to them, having patients and their families go home — and stay home.  

Want to learn more about our clinical programs? Email partnership@soundphysicians.com.