Health IT Answers: Advanced Precision Medicine Solutions Reduce VA Readmissions

Effectively assessing patients when they leave hospitals can play a vital role in reducing readmissions and advancing Veteran care.

Readmissions are often the result of insufficient pre-discharge planning and post-discharge management, such as incomplete instructions, medication errors and gaps in follow-up care, which can all put Veterans at unnecessary risk.

Fortunately, there are emerging precision medicine-focused solutions that enhance patient care coordination that can prevent readmissions, while also minimizing admissions through effective inpatient and post-discharge care. These solutions can harness algorithms, virtual learning, and predictive analytics to anticipate health outcomes and personalize Veteran care.

These were the key themes of a recent Health IT Answers guest articleby Jamie Leachman, RN BSN, senior product line manager at DSS, Inc.

Today's Readmissions and Discharge Management Challenges

The article also highlights the current readmissions and discharge management challenges that face today's health systems, including the Department of Veterans Affairs (VA).

A recent VA Health Systems Research study also found that, regardless of where Veterans lived, readmission after a VA hospitalization was more common than readmission after being treated at a non-VA hospital.

In May, the VA Office of Inspector General (OIG) issued a report around how the Veterans Health Administration (VHA) can best incorporate social determinants of health (SDOH) and health-related social needs (HRSN) into inpatient medical unit discharge assessments, planning, and policies.

In addition, a recent NIH (National Institutes of Health) study found that hospital readmissions within 30 days point to potential care quality issues, along with increased mortality risks. The study also highlights how high readmission rates can harm patient outcomes and financially strain care hospitals, as well as invite penalties and discourage potential patients from seeking care.

Precision Medicine and Discharge Management

One of the core tenets of precision medicine is to allow care practitioners to predict more accurately which treatment and prevention strategies for a particular disease will work in which groups of people.

Precision medicine also often considers differences in people's genes, environments, and lifestyles, which is why the VA is moving more towards leveraging SDOH and HRSN data to reduce readmissions.

Our Comprehensive Care Coordination (C3) Solution

The DSS Comprehensive Care Coordination (C3) allows VA care providers to focus on enhancing patient care coordination, optimizing workflow efficiency, and mitigating health care risks with a key focus on prevention of readmissions.

With effective care coordination being front-and-center, C3 provides comprehensive inpatient and post-discharge care management, while making patient risk identification a critical priority.

Here's how:

• C3 allows you to leverage dashboards that are designed with the team workflows and care coordination in mind.

• This allows various team members effective patient status evaluation, while also enhancing team communication.

• This comprehensive approach enhances overall decision-making and improves patient outcomes across diverse care settings.

• C3 also offers a dashboard for emergency departments that identifies both actively registered and discharged patients with emphasis on identification of patients with prior hospital discharge within 30 days of an emergency department visit.

C3 and Precision Medicine

Our C3 solution is at the forefront of advancing precision medicine for the VA through future leaning developments that integrate predictive models. These future developments will allow for predictive analytics capabilities, advancing the solution to include precision medicine principles for future analysis of patients at high risk for readmissions.

By analyzing comprehensive patient data and integrating it with predictive models, C3 can enable health care providers to move from reactive to proactive care strategies.This approach improves patient outcomes, optimizes resource allocation, and makes health care delivery more efficient.

The solution often includes algorithms at the patient level to assess risk factors and predict outcomes. For instance, algorithms may analyze patient data in real-time to identify high-risk individuals who may require timely and proactive interventions. This could include predicting the likelihood of readmission based on clinical data, socio-economic factors, previous healthcare utilization patterns and mortality risks.

DSS aims to be at the forefront of precision medicine as it will help the VA enhance care coordination and prevent unnecessary hospital readmissions.

To learn more about our C3 solution, please click here. In addition, to learn more about how DSS is a catalyst for health care innovation and digital transformation for the VA, click here.

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