Challenge
A health system is fined when a discharged patient is readmitted within 30 days. For this system, congestive heart failure readmissions were higher than the local competition.
30-day readmissions
The month after discharge
A 30-day digital communication protocol for the window in which a readmission can trigger a penalty.
Approach
Patients were psychographically segmented at discharge. Messaging was automated. Care managers followed up only when a patient went red on the tracking dashboard.
Results
- 51,173Patients engaged
- −41%Readmission cut to 11.9%
- 617Patients avoid readmission
- $6.8M2.6 million/yr cost savings