From the Guidelines
To reduce hospital admissions for a healthcare program, implement a comprehensive disease management program, focusing on high-risk patients, and utilize strategies such as intensive patient education, close monitoring, and multidisciplinary care, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
Key Strategies
- Implement chronic disease management programs: Target conditions like diabetes, heart disease, and COPD with regular check-ups, medication management, and patient education.
- Provide home health services: Offer in-home care for high-risk patients to monitor their condition and prevent complications.
- Utilize predictive analytics: Identify patients at high risk for hospitalization and intervene proactively.
- Implement care coordination: Assign care managers to high-risk patients to ensure seamless care across providers and settings.
- Promote medication adherence: Use reminders, pill organizers, and follow-up calls to ensure patients take prescribed medications as directed.
Rationale
The 2022 AHA/ACC/HFSA guideline for the management of heart failure 1 recommends referral to multidisciplinary HF disease management programs for high-risk patients to reduce the risk of hospitalization. Additionally, the 2024 standards of care in diabetes-2024 1 highlight the importance of proactive care transitions from inpatient to outpatient to prevent readmission. By focusing on prevention and proactive management, health plans can significantly reduce the need for costly hospital admissions, as supported by the 2005 ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Strategies to Reduce Hospital Admissions
Several strategies can be employed to reduce hospital admissions for a healthcare program, including:
- Transitional care initiatives, which have been shown to reduce hospitalizations by 20% among high-risk Medicaid recipients with complex chronic medical conditions 2
- Care coordination interventions, such as those provided by master's-prepared clinical nurse specialists or physicians specializing in palliative care, which can reduce hospitalizations and emergency department visits 3
- Implementing six key features of care coordination, including:
- Supplementing telephone calls to patients with frequent in-person meetings
- Occasionally meeting in person with providers
- Acting as a communications hub for providers
- Delivering evidence-based education to patients
- Providing strong medication management
- Providing timely and comprehensive transitional care after hospitalizations 4
- Addressing individual needs through care continuity and coordination, which can prevent avoidable hospitalizations 5
- Recognizing preventive care as an integrated part of the healthcare work to prevent avoidable hospitalizations, and engaging healthcare professionals in preventive care work 5
Effective Interventions
Effective interventions to reduce hospital admissions may include:
- Transitional care programs with intensive follow-up, which can reduce hospitalizations, emergency department visits, and costs 3
- Care management programs that incorporate the six key features of care coordination, which can reduce hospitalizations by 8-33% among high-risk patients 4
- Interventions that address individual needs through care continuity and coordination, such as those that provide timely and comprehensive transitional care after hospitalizations 5
Limitations of Certain Interventions
Some interventions, such as home health care, may not be effective in reducing hospital admissions for all patients, and may require focused attention on strategies to reduce readmissions 6