Post-discharge Automation: Strategies to reduce Unplanned Readmissions

By Robbie Hughes, CEO, Lumeon 

What happens when your patient leaves the consulting room?

At Lumeon, our view is that the biggest opportunity for improvement in the quality and cost of care delivered is to ensure that decisions made in the consulting room are followed up on in a timely manner, and that even after the patient has been discharged, feedback is exchanged regularly to ensure that progress continues to be made in recovery.

As we all know, the problem is that clinicians simply don’t have the hours in the day to make contact with every patient and to ensure that every plan made is properly executed. On the patient side, compliance with medical decisions is one of the biggest challenges the profession faces. According to data published by The Atlantic, 38% of patients don’t even follow their medication regimen.

The question, then, is how to use technology to bridge the gap. The traditional approach is to use portals and reminder services which engage patients in a relatively mechanistic way. These services make a difference where the patient chooses to engage, but the challenge is that the patient must choose to use them. If patients are unwilling or unable to take their meds on a regular basis, it seems like a stretch to assume that they would choose to jump through the hoops of a patient portal, unless there was a compelling reason driving them to this.

Online booking services have shown some success where the patient needs a service from the provider, and virtual consultations are taking off where the patient can source a medical opinion without having to leave the comfort of their own home. Where else, then, can we apply technology to the same effect, given the limitations of the patients reverting to old habits?

It turns out that the form of engagement needs to be appropriate to the patient. We know this from other industries, particularly marketing and advertising where the persona of the consumer has been so completely defined that individually tailored campaigns are structured around the specific engagement model that suits that particular individual. For example, we know not to make phone calls to senior executives during the working week and we know that attempts to call a new mother on the house phone after 7pm will rarely be received kindly. We know that appropriate engagement approaches that benefit the consumer will be well received. For example, patients coming in for surgery are inherently nervous, so sending communications to prepare them through what to expect can help calm them and engage them in the process. Equally, post discharge, particularly in the first few critical days, appropriate engagement to get an understanding of their pain level and recovery can be hugely beneficial both in terms of their perception of the overall experience, but also in terms of giving us indicators of readmission risk.

The key then is not to hyper-personalize the patient engagement, but to deliver it consistently, and evenly, to the right patients at precisely the right time for the patient. Specifically, if a patient is told that they will be contacted at 9 am on a Thursday following a Tuesday discharge, the absence of that contact can often be more damaging to the wellbeing of the patient than no specific promise of contact at all – that feeling of being ‘forgotten’ is hugely psychologically damaging. This level of personalization is where the context provided by pathways can help when combined with appropriate automation.

Today, Lumeon’s customers are deploying our pathway engine to personalize and automate patient follow up plans. These are combined with communication preferences of individual patients to ensure that each patient is contacted in a way that is appropriate for them. Each patient is put onto an individual plan with service levels and timers to ensure that if contact hasn’t been achieved, or specific information hasn’t been recorded, the system is able to escalate and adapt a new strategy that is a better fit for the patient being contacted.

This solution enables for patient care to be highly personalized but without the huge overheads that might otherwise be associated with this kind of care delivery. The solution can be used for lifestyle coaching, post discharge monitoring, pre-admission optimization and many other use cases that depend on better patient engagement, and, crucially, can be tailored precisely to the needs of the customer – we don’t advocate or restrict ways of working and collaborate with you to ensure that your strategies are implemented, and are configurable by you.