Feature Article

From Hospital to Home: Reducing Readmissions for Cardiac Patients

When post-discharge education, powered by technology, means the difference between life and death

It’s a grim, but important fact: Just a month after discharge, about 1 in 5 heart failure patients get readmitted to the hospital. At six months, that number jumps to 1 in 2.1

And even worse: Within a year, nearly 36 percent of them pass away, according to a national study of 3 million Medicare patients.2

Enter the HRPP

Given these numbers — and the fact that heart failure remains one of the top reasons for readmission3 — it came as little surprise when the federal government launched the Hospital Readmissions Reduction Program (HRPP). As a part of the Affordable Care Act, the program penalizes providers for readmissions of six diagnoses — heart failure among them.

Four of the other five all link back in some way to heart failure, too: heart attack, pneumonia, chronic obstructive pulmonary disease, and coronary artery bypass graft.4

But have those penalties worked? Yes and no, according to a much-publicized October 2017 study in JAMA. On average, hospitals have seen readmission reductions paired with slight decreases in mortality. But averages can masque low numbers, and the positive gains weren’t seen as much in heart failure — which had fewer readmissions, but more deaths too.5

How technology can help

So clearly, there’s more work to do. Reducing readmissions while improving outcomes after discharge has become top-of-mind for cardiology providers, and the three most effective ways to do it also happen to be the most cost-effective, too:

  1. Medication Adherence (helping patients take all medications as prescribed);
  2. Post-Discharge Compliance (giving patients an easy-to-follow care plan after discharge);
  3. Follow-Up Care (helping patients follow their care plan via phone and in-person follow-ups).

Luckily, technology can help with all three — and it all comes down to keeping patients involved in their own healthcare, from hospital to home and everywhere in between. That means giving patients plain-English information in a way that’s most accessible for them.

After all, when patients are fully engaged, they’re not only more likely to be proactive about improving their health; they’re also more likely to get regular care and participate in wellness programs. All this helps reduce cost and improve outcomes, too.

Providers just need to find the right tools to do so. These are a good start:

1. Post-discharge mobile apps

The rise of post-discharge mobile apps has cleared a role for education in a patient’s day-to-day. Before, patients would leave the hospital clutching a folder-full of printed materials that they might never look at again.

But with post-discharge apps, patients can access those materials, track their progress, and get medication info at their own pace, on their own phones — and for some, talk to their doctors or nurses with the tap of a button.

Providers who have used Get Real Health’s InstantPHR have already seen such benefits. As a 200-piece toolkit accessible via mobile or web, the app empowers patients to access their health information, message their providers, and follow action plans for their care.

The benefits go both ways. For providers, apps like the InstantPHR help doctors manage chronic diseases like heart failure and share important alerts with their patients — and monitor the patient’s progress, too.

2. Remote health monitoring

With advances in telemetry, patient monitoring doesn’t have to end at discharge. Through integrated systems, sensors, and scales that keep track of patient health remotely, providers can help spot and address warning signs before they lead to another hospitalization.

Take the AirStrip ONE Mobile Platform. It synthesizes data from several inputs (bedside monitors and home-based sensors alike) into one dashboard for viewing on iOS, Android, and web-based platforms. Others like it can send patients home with health sensors, scales, or wearable devices to remotely monitor their health and anticipate potential problems.

The Care Innovations remote patient monitoring (RPM) program is another example of how remote models can transform post-discharge cardiac care. Blending educational materials with behavioral support and advice at recognized "teachable moments," the RPM system has demonstrated its success in tracking patient health, trends, adherence, and signs of exacerbation.

Such features yielded a 64 percent reduction in readmissions, according to a randomized control study that assessed the Care Innovations program. From a longterm perspective, the platform produced an 18 percent increase in patient activation measurement (PAM) engagement, equating to a 21 percent cost cut compared to lower PAM levels.6

Plus, new technologies could take it one step further. By marrying that monitoring data with genomic data, doctors could even have a full-picture look at their patient’s progress to help craft individualized plans, improve outcomes, and help preempt readmission even more.

3. Specialist-to-PCP transitioning

The essential handoff between cardiologist to primary care physician (PCP) shouldn’t be overlooked — and equipped with technology, PCPs can greatly support patient education after discharge. At least, so says research.

In 2014, researchers sought to find out which strategies led to lower readmission rates. They found that when PCPs were kept in the loop of their patient’s discharge info, readmission went down.7

So naturally, having an all-in-one dashboard that can synthesize a patient’s intake-to-discharge records into an easy-to-send report for primary care doctors isn’t just nice to have. It’s critical.

For many, systems like Centricity Cardio Enterprise* have made it happen. Through the kind of high-powered reporting,  interface and workflow technologies that have reduced report turn-around times from 7 days to just 1, specialists can get results into the hands of the broader care team, including the PCP, more quickly. This enables the primary care provider to include the cardiologist’s care plan into their own.

A changeable problem

So indeed, rates of readmission may be grim — but they’re changeable. And with post-discharge education in the hands of both patients and providers, that technology could indeed change everything — from reducing hospital readmissions to bettering outcomes for all.

And that, quite frankly, could be the difference between life and death for many patients.

*Centricity Cardio Enterprise is comprised of Centricity Cardio Workflow and Centricity Universal Viewer


  1. High Heart Failure Readmission Rates. JACC Heart Failure. http://heartfailure.onlinejacc.org/content/5/5/393. Accessed 18 April 2018.
  2. Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study. The BMJ. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353309/. Accessed 18 April 2018.
  3. The Prevention of Hospital Readmissions in Heart Failure. Progress in Cardiovascular Diseases. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4783289/#R5. Accessed 18 April 2018.
  4. Readmissions Reduction Program (HRRP). Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed 18 April 2018.
  5. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. JAMA. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5817448/. Accessed 18 April 2018.
  6. Data provided by Care Innovations.
  7. Hospital Strategies Associated with 30-Day Readmission Rates for Patients with Heart Failure. Circulation: Cardiovascular Quality and Outcomes. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3802532/. Accessed 18 April 2018.