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Reduce Post-Hospital Syndrome & Readmissions

The work of a patient and their family is never more important than when going home from the hospital. During the hospitalization, health professionals focus on diagnoses, treatment, and the transfer to home safely. Yet for those going home, it’s a tricky time. There are new issues and medications, special diets, with ongoing symptoms such as pain and fatigue. Daily routines can change, with sleep disrupted and diminished physical abilities. Mood may be lower, making recovery even harder and more prolonged.

The intense attention at the hospital bedside transitions to minimal help at home. Patients are vulnerable during the immediate days and weeks after hospitalization. Yale cardiologist Dr. Harlan Krumholz coined the phrase “post-hospital syndrome” in a New England Journal of Medicine article 10 years ago, describing the risk of going back to the hospital and the necessity of mitigating this burden.

To eliminate gaps in post-acute care and lower readmission rates, Medicare created codes for transitional care management, or TCM. TCM goals are timely outpatient services and delivering needed support and care at home. Practices can be reimbursed for: patient outreach within 2 days of discharge; reviewing data, addressing patient needs, and linking to resources; and having an ambulatory visit within 1 to 2 weeks, depending on the level of medical complexity.

The facts are important here. While TCM has been shown to improve care at home and lower readmissions, less than 1 out of 5 patients discharged home receive TCM services. In addition, practices that provide TCM services are burdened with having sufficient resources, having success reaching patients at home, and seeing patients follow-through with visits.

How can practices increase and improve their TCM services? A simple and low-cost method is to use automated bi-directional text messaging. Texts reach a wider population, without a need to have broadband or smartphone apps – important issues for older adults. For the care team, texts offer automated outreach and can collect critical data needed for transitional care. A recent randomized trial in JAMA showed that automated texting lowered readmissions.

Florence intelligent health messaging can fill the gap from hospital bed to bedroom at home. Flo easily reaches patients discharged home and can serve as a core of TCM services. With compassionate conversations, Flo reminds, nudges and supports for continuous care at 30, 60 or 90 days. She can ask about needs at home and identify problems earlier – so care teams can intervene in a timely manner, and to help people avoid post-hospital syndrome.

In their paper in the International Journal of Technology Assessment in Health Care, Rezgui et. al. used Florence after a hospitalization for Covid, with over half of patients on home oxygen. Flo safely supported a ‘hospital at home’ setting, appropriately signaling those who needed a greater level of care.  

In an effort to improve post-discharge care for patients with heart failure, Flo was instrumental in achieving a 45% reduction in re-admissions to the hospital.  

Learn more about the evidence of how Florence helps people stay where they need to be: At Home

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