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Increasing Patient and Caregiver Engagement to Reduce Readmission Challenge

Efforts to reduce “30-day hospital readmissions” continue to be a challenge for Henry Ford Health System, as well as for other U.S. providers. In an ongoing effort to improve performance, hospitals have implemented predictive tools to identify high risk patients, utilized more intensive discharge education, deployed case managers and home care nurses for support. In spite of these intensive efforts, hospital readmission rates have not shown significant improvement. The underlying cause of hospital readmission is multifactorial and includes barriers related to social determinants, insufficient support in the home, complex medical conditions, lack of understanding the treatment plan, and lack of patient engagement.

One of the most significant challenges is identifying and deploying strategies to improve patient and caregiver engagement. These could include patient education with validation of understanding, tracking health information to manage complex medical conditions and treatment plans, adhering to difficult medication regimens, and completing required follow up care. Innovative approaches to improving patient engagement in the discharge process are expected to improve readmission rates and overall quality of life.

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