Acute Myocardial Readmission Reduction Program: “Never Discharge A Patient”

Readmission for Acute Myocardial Infarction [AMI] significantlycontributes to preventable morbidity and healthcare costs.Nearly 1 in 6 patients hospitalized with AMI have an unplanned readmission within 30 days of discharge, accounting for over $1 billion of annual US healthcare costs.We developed a unique integrated product in our hospital called "Transition of Care" program [TOC] with the help of technology and services from Patient Engagement Advisors.The TOC program was based on the notion that engaging patients in their self-care journey by provision of extended set of products and facilities, nutrition, medications, and services to meet their care and recovery needs across the continuum of care.The TOC program led to the subsequent reduction in the AMI readmission and significant cost savings by avoiding Medicare penalties.AMI readmission rates were reduced to less than 20% since implementation and have fallen below expected rates.This has translated to more than $ 400,000 savings in penalties as the actual readmission rate has been under the expected rate.It also led to improved clinical follow up in the post AMI patients and improvement in clinical parameters in patients with chronic conditions like diabetes and hypertension.The TOC program extends health care beyond the four walls of the medical care facility and never truly discharges the patient.