Strategies to reduce costly hospital readmissions and improve patient care [PODCAST]

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We explore the pressing issue of hospital readmissions and their significant impact on health outcomes and financial strain within the health care system. Our guest, health care executive Ahzam Afzal, shares insights into the strategies and challenges of reducing readmission rates, including the role of data-driven care, cohesive communication, and effective care coordination. We delve into how staffing shortages affect the implementation of new CMS programs and discuss practical solutions for supporting patients post-discharge to promote better outcomes.

Ahzam Afzal is a health care executive.

He discusses the KevinMD article, “Effective strategies to reduce hospital readmissions amidst staffing shortages.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Ahzam Afzal. He’s a health care executive. Today’s KevinMD article is “Effective strategies to reduce hospital readmissions amidst staffing shortages.” Ahzam, welcome to the show.

Ahzam Afzal: Thanks for having me, Kevin.

Kevin Pho: So start by sharing your story and journey.

Ahzam Afzal: Yeah, so a little bit of background. I’ve been in this value-based care world for the last decade. I initially started out as an executive at CVS. I started building out a lot of medication therapy management programs, and the goal of that was really to design programs that were to help reduce readmissions, drive down total cost of care, and enhance medication therapy management. I did that for a number of years and helped to really drive down the total cost of care in those specific segments. I think consistently one of the challenges, in primary care as well as in the outpatient pharmacy world, is that patients just didn’t have the resources or the reminders or the technology in place to ensure that they were compliant with their medications or adhering to their medications, and I helped build out some programs doing that.

Since then, back in 2015, CMS actually rolled out a program called chronic care management. That was a program that was designed to ensure that patients were more compliant with their medications and more adherent to their medications, but it was also designed to ensure that in between office visits there was a system in place to check in on patients, set care goals with the patient, and ensure that they’re not essentially getting hospitalized. So that program was launched in 2015, and then I started one of the first chronic care management companies shortly after that. The goal of that program was to ensure that patients were more adherent to their therapies and to their treatment plans. We grew that across eighteen states, served around sixty thousand unique lives, and later exited that venture to a firm in New Jersey.

But through that work, I had an opportunity to work really closely with a number of different ACOs and other health systems, and then also to work closely with CMS Innovation on a few different initiatives. The discussion point continually was that there are specific areas in health care that are areas of high cost, and one of the areas that consistently came about in terms of high cost was this post-acute care segment. The post-acute care market tends to have one of the highest areas of spend, and it’s because of the fact that these are the patients that are the sickest of the sick, the highest-acuity patients. There was a big need to ensure that these patients had the right follow-through of care through the care transitions, from the point of hospital discharge through the entry point into these post-acute facilities, the SNFs, and then also when they go home for that period of ninety days post-discharge. It’s a very high-cost area for CMS and for the health system.

So then I started a company called Puzzle Healthcare as a result of those big issues that we identified, and that was about three years ago. It was really designed to tackle this readmission problem that’s been in place now for almost a decade. The goal of that program is to ensure that patients have the right care and the right support through the transitions of care. Now we’ve been blessed enough to work with some of the largest health systems across the country and have been able to get really, really strong readmission rate reductions with some of our biggest health system partners, OSF HealthCare and Corewell Health out here in Michigan. Now I think it’s being able to extrapolate that more on a national scale, and that’s what we’re looking to do. I’m excited to talk further about how we can solve this problem together.

Kevin Pho: Sure. So let’s talk more about those strategies to reduce readmissions in your KevinMD article. For those of you who get a chance to read it, tell us more about it.

Ahzam Afzal: Yeah, so the article really came from years of this firsthand experience of observing how critical these hospital readmissions are to both patient outcomes and the economics of health care. For context, hospital readmissions are costing the U.S. health system over $52 billion on an annual basis, and many of these costs are concentrated in these high-risk, high-cost areas like cardiology, specifically in chronic disease management, as well as post-acute transitions. The fact that nearly 15 percent of these newly discharged patients are readmitted within 30 days underscores that there are a lot of systemic inefficiencies that persist in our system.

So in writing the article, I wanted to address not just the magnitude of the problem but also the root causes, especially in the context of staffing shortages in the post-acute space. Post-acute care in particular, in the context of staffing shortages, is one area that’s pretty large, and it’s a critical leverage point in value-based care models, because these facilities manage some of the sickest and most complex patients, and yet they’re often the most under-resourced facilities. They’re understaffed, and they’re disconnected from the broader health care system. As a result, there are a lot of missed opportunities for interventions, there are poorly managed care transitions, and there are preventable readmissions that occur as a result of that.

Then I structured the article around three core strategies that I believe are foundational to solving this readmission problem. The first thing that I touched on was data-driven care delivery. Data is, I’d say, the backbone of any sort of value-based care initiative, and without having any sort of actionable insights, clinicians are really flying blind. So having these predictive analytics in place can help us identify patients that are at highest risk for readmission. Those are generally ones with poorly controlled conditions that have these multiple comorbidities or social determinants of health that make it harder for them to recover at home. But the real challenge isn’t just identifying these patients; it’s intervening in more of a real-time fashion.

At Puzzle, what we’ve done is we’ve implemented a lot of these real-time monitoring tools that are tracking patient vitals in skilled nursing facilities and even at home, and these are enabling us to flag early signs of deterioration, allowing care teams to step in before a patient ends up back in the emergency room. When we think of these core conditions like CHF, for example, oftentimes there’s weight gain, increased shortness of breath, or abnormal blood pressure that’s detected through some of these monitoring technologies, and a simple medication adjustment is really able to ensure that we’re able to prevent a readmission like that. So that’s the power of that data-driven care delivery. We’re leveraging a lot of different platforms and other things that we’ve also seen in health systems and also in skilled nursing facilities, like radar sensor technology and some of these other items, that enable more visibility and clear visibility as to what patients are experiencing when they leave the hospital and enter into the skilled nursing facilities.

Then the other piece of it is just cohesive communication across the care continuum. This is, I think, often the place where the system breaks down. A patient may leave the hospital with a detailed care plan, but if the SNF staff, the primary care providers, and the specialists aren’t on the same page, there are a lot of critical details that are going to get lost along the way. These communication gaps are going to lead to medication errors, missed follow-up appointments, and exacerbations of their conditions, all of which are going to cause readmissions to skyrocket. The goal there is to ensure that there’s a streamlined and consistent centralized EHR solution in place between the hospital, the SNF, and during that post-discharge window, to ensure that everybody has the right information needed to interact across the board and get the right results across the board. But it’s not just the technology piece; it’s also just standardizing workflows. For example, when a patient transitions to a SNF, there should be a structured protocol for, let’s say, medication reconciliation or care plan handoffs and follow-up schedules. These small steps make a huge difference in preventing those unnecessary hospitalizations.

Then lastly, I think the third pillar that’s there is perhaps the most important: empowering patients and caregivers. Even with perfect care coordination in place among the providers, patients are ultimately bearing much of that responsibility for their recovery, and expecting them to manage their complex medication regimens or follow care plans without support is unrealistic. In the article, I talk more about practical solutions like leveraging digital tools to send medication reminders, offering these telehealth check-ins, and providing patients with personalized care plans that are easy to understand. For example, for patients discharged at home, we’ve seen a pretty great amount of success with RPM, remote patient monitoring, combined with regular telehealth follow-ups. This combination ensures that patients don’t feel abandoned once they leave a facility, and it gives providers a way to intervene proactively when something goes wrong.

Kevin Pho: So give us maybe a couple of case studies that would really chart that post-discharge course and how some of these technologies that you mentioned would really move the needle. So give us some case studies, and maybe you can include my role as a primary care physician, about how I would intersect with that.

Ahzam Afzal: Yeah, for sure. So one of the things that comes to mind is, initially, when you see patients that are, let’s say, leaving the hospital and going into a SNF, they’re getting some sort of rehab in the facility, and then they’re going into that post-discharge window. One of the big challenges that we face is: Are the patients safe enough or healthy enough to get through their ADLs and make sure that they can function and operate in a way that they can go back to their prior level of functioning before they were actually hospitalized?

So for us, what we’ll do is, one of the technologies that we’ll deploy is a remote patient monitoring sensor that’s more of a health sensor. It’s like a health tag, for example, that sticks on the articles of clothing. Typically, it’s placed on the undergarments. It’s machine washable, the battery lasts twelve months, and it tracks heart rate, respirations, movement, and activity levels. So now, when our care management teams are, let’s say, reaching out to Mrs. Smith post-discharge, we can notice that she hasn’t been out of bed in a couple of days, or we notice that her respirations are increasing, which could potentially indicate that there could be some sort of infection risk or something that could be deteriorating. Heart rate and respiratory rate are the two most common predictors of patient deterioration, so having that information on more of a real-time basis really helps drive outcomes. It really helps drive care teams to have the right level of insights, to collect not just information from what the patient’s telling you, but then also to look at it objectively and say, “Hey, this matches exactly what we’re finding on the vitals and the RPM panel that’s there.” That really helps to proactively address a lot of these issues.

But then, additionally, you take it a step further and say, now that you have all this information, how do we ensure that the health system partners are also collaborating to ensure the patients have a place to go versus getting hospitalized? OSF HealthCare has been a great partner of ours, and they’ve set up eight high-acuity clinics that are really designed to ensure that when patients are having exacerbations that may not be hospitalization-worthy, but there could be a chance where we need to triage them and maybe manage their condition in more of, say, an observation stay versus a hospitalization stay or admission, those high-acuity clinics serve as a good place to refer and send patients to when those issues do occur.

Then in the SNF world, when patients leave the skilled nursing facilities, if they’re within that first thirty-day mark post-discharge, that is a window where the patients can go right back to the facility, because they’re still within that coverage window that’s there, and facilities are typically good partners to route those patients back to in the event that that happens.

Kevin Pho: So in most of these post-discharge cases, you have patients wear some type of remote monitoring device where they can transmit the data back, and then once they find that the patient may potentially be rehospitalized, you have these post-acute facilities that can, I guess, intercept them before they go to the hospital to see whether they could be corrected. Is that fair to say?

Ahzam Afzal: Yeah, exactly. That’s more the brick-and-mortar solution, having them go to the high-acuity clinics, but at least initially, it’s the triaging with the nursing team that’s identifying the issues. Then there’s also a telehealth component, to ensure that we have, let’s say, an ER physician on standby who can enter into a telehealth encounter to say, “Hey, is this patient worthy of going to a high-acuity clinic?” The health system partners that we have will leverage a lot of their ER docs and some of their other providers to have those types of discussions with our care teams, to say, “Yep, this is one that would go to the high-acuity clinic versus just going to the hospital.” So it really helps us to triage the level of care that’s being provided across the board.

Kevin Pho: So tell us what kind of outcomes you have. You said that you work with several large systems in Michigan. Tell us some type of outcomes data from your technology.

Ahzam Afzal: Yeah, so when we first started the company, the first health system partner that we had was OSF HealthCare. OSF HealthCare has about seventeen hospitals. They’re the largest health system in the state of Illinois in terms of hospital count. When we engaged with them, they had a huge problem with readmissions, particularly as it related to patients that were leaving the hospital, going into a SNF, and then going home. They tracked that readmission rate: About 29 percent of patients that were leaving the skilled nursing facilities, who were originally coming from OSF, were bouncing back to the hospital. It was really just a matter of not having the follow-through care when the patients were leaving the skilled nursing facilities.

So when we came in, it took us, I’d say, about three or four months to fully get embedded in about seventy-five or eighty skilled nursing facilities that were all part of their post-acute discharge network. After engaging with them, after a year of the program, we were able to bring their readmissions down from 29 percent to 9 percent in one year. When we initially got introduced to them, they had lost a little over $1 million over the last two years in terms of readmission penalties and a lot of the costs that were there. So there was a significant amount of savings that was really coming from the reduction in total spend in the post-acute space. So that’s one instance.

Then there’s Corewell Health, which is the largest health system in the state of Michigan. We’re working with the Beaumont ACO out here, which manages the post-acute network of skilled nursing facilities for Corewell Health East. They have about fifty to sixty skilled nursing facilities that they discharge their patients to, and they also have opportunities with readmissions. When they did their analysis, and a lot of ACOs will do this analysis, they look at: What are our highest areas of spend across the board? Post-acute, consistently across the country, tends to be one of the areas where there’s the highest amount of spend, just because it’s a sick, high-acuity population. What we discovered through that partnership, now that we’ve been working with them for a little over a year: Their results recently came back, and they’re now in the top 5 percent, so the 95th percentile in the country, in terms of post-acute spend. Historically, they’ve done really well across the board, but that post-acute area was an area of opportunity, and by layering in programs like this, we’re starting to see even ACOs as well as health systems really drive down the total cost of care in that post-acute segment.

Kevin Pho: So any barriers or obstacles that you had in trying to expand this post-discharge technology?

Ahzam Afzal: I’d say recently we’ve had more adoption. The way I look at it is, sometimes you think of primary care, and sometimes health systems are a little more innovative in their thought process, but for some reason skilled nursing facilities are lagging behind in that. A lot of times, skilled nursing facility operators are kind of stuck in more of an archaic fashion of maybe doing things, of how they always used to be done. So I think there’s a little bit of change management with skilled nursing facilities, who say, “Hey, this is how we’ve done things for the last fifteen or twenty years. Why should we do anything different at this point?”

So that’s why, for us, it was important to engage a key health system partner in a large state, get the buy-in, and get the results. Now where we’re at is a lot of the health systems are now looking to add these solutions to their skilled nursing facility partners, and when the skilled nursing facilities are hearing it from the health systems that essentially are the referral source, they want to ensure that their health system partners are happy at the end of the day, just because it helps with the continuum of care. Now we’re starting to see that. So I think the biggest thing is change management in this market.

Kevin Pho: We’re talking to Ahzam Afzal. He’s a health care executive. Today’s KevinMD article is “Effective strategies to reduce hospital readmissions amidst staffing shortages.” Ahzam, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Ahzam Afzal: So I think the health care system today is still too often built around processes and silos rather than the patients it’s meant to serve. So I think my take-home message I want to leave is that we need to fundamentally rethink how we approach the patient experience, and it starts with asking ourselves one critical question: What does the ideal health care journey look like from the patient’s perspective? For me, the answer is a system where every touchpoint, whether it’s a hospital, a skilled nursing facility, or a follow-up telehealth visit, feels connected, feels seamless, and feels personalized. Patients shouldn’t feel like they’re navigating a maze or falling through the cracks; instead, they should feel supported and empowered every step of the way.

To achieve this, I think we have to move beyond simply treating episodes of care and embrace more of an approach that’s truly longitudinal in nature. That means leveraging technology not just to predict and prevent adverse outcomes, but to actively shape better patient journeys across the way. So predictive analytics, remote patient monitoring, and AI can give us the insights we need to intervene early, reduce the readmissions, and personalize care, but these tools must be paired with a commitment to the empathy and the communication, and really understanding what a patient is going through.

When I think of this, I think of a health care system where a patient is discharged from the hospital. Imagine a world where they’re discharged from the hospital and they’re automatically connected to a care team that spans their primary care provider, their post-acute facility, and even community resources. Now this entire team is equipped with real-time data, and they practically reach out to the patient, not just to check vitals, but to ask how they’re feeling, address barriers to recovery, and ensure they understand their care plan. That’s the kind of transformation we’re talking about: making the patient experience proactive and not reactive.

What we’re seeing is that ultimately the patient experience is about trust. When patients feel cared for, when they know their providers are communicating, their transitions are smooth, and their concerns are heard, they’re more likely to engage in their own care across the board. Patients that are leaving the hospital are oftentimes in a very vulnerable state, and they don’t have the right supports at home or the right setup at home to ensure that they fully understand their care plan. I think for us, it’s making sure that we try to put the patient first, and the technology and the data and everything around it. I think that’s what leads to better outcomes, and it yields better outcomes across the board, not just for the health systems, not just for the skilled nursing facilities, but most importantly for the patient.

Kevin Pho: Awesome. Thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Ahzam Afzal: Thanks.

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