The Key to Reducing Readmissions? Coordinated Care Transitions and the MEDITECH EHR

March 5, 2015 - With the Centers for Medicare and Medicaid Services (CMS) now using a risk-standardized excess readmission ratio to reduce hospital reimbursements, MEDITECH is helping its customers to keep their readmissions low and avoid penalties.

Under the Affordable Care Act (ACA), hospitals with high readmission rates now face penalties totaling up to three percent.

With its fully-integrated EHR, Medical Information Technology, Inc. (MEDITECH) supports the coordinated care transitions that help healthcare organizations eliminate unnecessary readmissions and maintain their bottom lines. Several key system features give providers the tools they need to see a complete clinical picture of their patients, inside the hospital as well as outside of it.
Multidisciplinary Approach to Care Management and Discharge Planning

MEDITECH’s customizable Surveillance Status/Quality Boards enable providers to track various readmissions measures based on administrative data, medications, lab values, radiology results, and other risk factors. Access to clinical results enables the team to monitor their patients’ conditions and quickly take steps to support best practices and avoid adverse events. Quality managers can closely monitor the patient’s progress throughout their admission.

MEDITECH supports customers in following industry recommendations by initiating discharge planning when the patient is first admitted into the hospital. An integrated approach to discharge planning ensures better coordination by enabling caregivers to easily review the patient’s status and share pertinent information with one another. Care transitions managers can track the patient’s progress, manage follow-up care, and document patient interactions—thereby reducing the readmissions risks correlated with discharge processes.

Comprehensive Medication Reconciliation

Patients taking four or more medications often have a higher risk for readmission. MEDITECH’s comprehensive medication reconciliation ensures the highest level of patient safety through inherent integration between our inpatient, ambulatory, and home care solutions. During the reconciliation process, the Discharge routine alerts the provider to medications missed. In addition, medication orders converted from inpatient to home are automatically accessible to home health agencies, hospices, and ambulatory care providers.

If a patient sees a provider outside the network, his or her medication history—as documented in the provider interview—is included in the Transitions of Care summary, supporting accurate medication reconciliation across your community while also helping to reduce readmissions as a result of polypharmacy complications.

Continuity of Care

A Consolidated Clinical Document Architecture (CCDA) Transitions Care Summary ensures that when a patient transitions from an acute care setting, important and actionable information follows him or her to the next point of care. MEDITECH enables an organization to use a CCDA to share information in two ways—you can securely and automatically send a CCDA to providers via Direct Message, and/or publish the CCDA summary to a Health Information Exchange (HIE) Repository or another EHR solution.

Post Acute Care

MEDITECH’s ambulatory solution supports the PCMH model in a variety of ways. Staff within physician practices can easily share and access real-time patient data, allergies, prescriptions, medical problems, progress notes, reports, and notifications across the enterprise for improved patient safety. Secure and intuitive messaging is also available to help coordinate care across your organization.

Our integrated Home Care solution receives key patient information including condition-specific protocols in real time. Care transitions managers can begin the referral process and plan a patient’s home health or hospice admission while the patient is still in the hospital.

Additionally, MEDITECH’s Telehealth Home Connect helps your organization monitor and identify patients who may be deteriorating, while also providing the tools your care transitions manager or home health nurse needs to intervene early, before emergency department visits become necessary.

Patient Engagement

Patients who are informed and empowered are more likely to engage in self care management that will keep them out of the hospital longer. MEDITECH’s web-based Patient and Consumer Health Portal provides a secure and confidential tool for them to proactively engage with caregivers and better manage their own care.

Patients can conveniently review and update their health records, manage appointments/prescription renewals, access discharge materials, and communicate with providers confidentially via secure messaging.

Want to Learn More?

Find out more about how MEDITECH can help your organization to reduce readmissions and comply with CMS guidelines. Customers, download a copy of our white paper, Reducing Potential Readmissions with Your MEDITECH EHR. And be sure to visit our booth #6315 at the upcoming HIMSS15 in Chicago, April 12-16.