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A hospital readmission occurs when a patient is admitted to a hospital within a specified time period after being discharged from an earlier (initial) hospitalization. For Medicare, this period is defined as 30 days and includes hospital readmissions to any hospital, not just the hospital at which the patient initially was hospitalized.  In 2011 CMS primary focus was to reduce the 30day CHF readmission rates, with the overall goal of improving patient center care while adding educational and motivational techniques to produce positive outcomes and mitigate readmission rates. On October 1, 2014, CMS added Total Joint Replacement and COPD in addition to CHF, AMI, Pneumonia, on October 1, 2013, to be penalized for readmission within 30days; the penalty will range from 1% to a max of 3% in October 2014.

In Medicare’s current climate they use an “all-cause” definition of readmission, meaning that hospital stays within 30 days of discharge from an initial hospitalization will be considered readmissions, regardless of the reason for the readmission. This all-cause definition used in calculating both the national average readmission rate and each hospital’s specific readmission rate. Today the total Medicare penalties assessed on hospitals for readmissions will increase to $528 million in 2017, $108 million more than in 2016.

Partnering to Reduce Avoidable 30Day Readmissions

Are you prepared for upcoming reimbursement shift from fee-for-service to value-based care?  Hospitals and Skill Nursing facilities are evaluating their current 30day readmission rates, to improve processes and partner alliances in reducing readmissions.

Our @HomeCore Solutions™ 5 Pillar of Enhanced Care Model is the first program of its kind utilized in the home to work collaboratively and has proven results in the reduction in hospital readmissions. At the foundation is our Disease Management tool an evidence-based, condition-specific care program focused on empowering the patient to better manage her/his chronic illness through active involvement and is modeled after nationally recognized VNA clinical pathways. Under the direction of our Case Manager in collaboration with the primary physician, we utilize an evidence-based intervention and educational protocols to ensure the patient progress towards positive outcomes ultimately leading to self-management.

Together we can reduce readmission rates with our comprehensive @HomeCore Solutions™ bundled service offering focusing on continuously improving the health care needs of the patients by delivering value-driven, high-quality compassionate care. Since 2003 our mission has been focused on consistently delivering operational excellence to our clients, partners, and communities we serve. Our clinical and management expertise encompasses 60 years of patient-centered care best practices focused on a proven triple aim approach of Engagement, Education, and Empowerment of the patients and their families.

Our @HomeCore Solutions™ operational excellence ensures:

• Hospitalization Risk Assessment
• Real-time monitoring trended patient reporting
• Health care management servicing 24/7
• Provides peace of mind to our clients and partners we serve

30Day Readmission Reduction:

At Assure we have identified every patient diagnosed with CHF, COPD, Pneumonia, and AMI have the greatest potential to be readmitted. We have designed our @HomeCore Solutions™ Programs to mitigate readmissions by empowering the patient with knowledge of disease management to self-management.

It’s all about preventing the preventable identifying at-risk patients after discharge (above and beyond the typical frequent flyer approach) so that issues is addressed long before a return visit to the hospital or ED becomes necessary. Maintaining every step in the continuity of care for these patients is critical and our #1 GOAL with our CALL ME FIRST campaign and ZONE MANAGEMENT Education tool was introduced in 2011.

Transitional Care:

Reducing Readmission and Improving Care Transition is our top priority at Assure. The transition that takes a patient from the hospital to their home or another care setting marks a pivotal care moment in their recovery. Our Transitional Care Management Model consistently delivers improved patient outcomes among high-risk patients. Doctors, patients, and loved ones trust us to provide seamless care and monitoring when patients are preparing for discharge from the hospital to their home or assisted/independent living facility.

When a physician refers a patient to us for home health care, our planning begins while the patient is still in the hospital. Our Transitional Care Nurse (TCN) meets personally with the patient and family members to gain a comprehensive understanding of the patient’s needs and prepares the transition of the Patient to their home setting helping the patient work toward recovery and continued independence.

@HomeCore Solutions™ CHF Disease Management:

Assures CHF @HomeCore Solutions™ is a multidisciplinary program designed to assist patients and physicians in the effective management of congestive heart failure (CHF). This program is designed to minimize hospital readmission’s geared towards educating heart-failure patients and empowering them to self-manage their condition.

• Transitional Care Management
• Clinical Management Model
• Congestive Heart Failure (CHF) Disease Management
• Medication Reconciliation
• Telehealth Monitoring

@HomeCore Solutions™ CHF Objectives:

Many of these return trips to the hospital can be prevented by the use of our collaborative CHF @HomeCore Solutions™ bundled  program offering which involves the patient, physician and care providers in reducing the 30day readmission rates by providing and yielding positive outcomes to improve and reduce rehospitalizations:

• Increase intervals between hospital admissions
• Reduce ER visits
• Improve patient compliance
• Promote self-management capabilities
• Improve and enhances quality of life
• Regain independence

“Nearly 5 million Americans have heart failure, and 1.3 million of those people end up being readmitted to the hospital – in fact, heart failure has the highest readmission rate of all chronic diseases. Readmission is stressful for patients and their families, and they’re costly to hospitals.”


Since 2007 Assure has taken the lead in providing telehealth monitoring services to patients with chronic diseases at NO cost to the patient, physician or facility. This proactive stance incorporating TeleMonitoring technology has saved countless health care dollars by helping to reduce hospitalizations and the use of emergent care services.

We believe this tool is critical to quickly deploy interventions and assessment responses to mitigate unnecessary readmissions. The readings are transmitted real-time to our Case Managers on a daily basis reporting the patient’s condition, trending out of range vital signs, medications adherence and are monitored for any signs or symptoms of illness changes and are directly reported to the attending physicians for changes to the care plan.

Home telehealth involves the use of technologies in the home setting that allow patients away to self-manage the recovery and disease process. Thus, it could be said, that home telehealth extends the eyes, ears, and touch of home care, bringing specialized medical monitoring to people who need it the most, as a supplement to in‐person home visits and not to be utilized.