Mike’s Metrics: From Hospital to Home: Norman’s Successful Care Journey with Digital Solutions

by | May 25, 2023

As healthcare providers, your top priority is to ensure that patients receive the best care possible. Part of that care is ensuring that patients have a smooth transition from the hospital to their homes.

Meet Norman, a 77-year-old patient, and learn about his personalized digital care journey.

Norman’s story is just one example of the positive impact that digital care plans can have on patients’ health outcomes and healthcare costs. As the healthcare industry continues to appreciate the value of proactive care, providers must increase engagement in order to improve patient outcomes and reduce readmissions.

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In Norman’s case, his hospitalization for COVID complications in 2020 was compounded by a heart failure diagnosis. Two days ago, Norman was admitted for a respiratory infection. Since heart failure has the 2nd highest number of 30-day adult hospital readmissions, he was at a high risk of readmission within 30 days of discharge. This situation not only poses a significant health risk to Norman, but it also carries a financial risk, as heart failure readmissions can cost upwards of $15,000 per patient. (costs reflect the actual expenses incurred in the production of hospital services, such as wages, supplies, and utility costs).

Fortunately, upon discharge, Norman received a proactive digital care plan that included education, follow-ups, and referrals to appropriate specialists. He was also given a remote patient monitoring device to track his pulmonary health. By using these tools, Norman was able to manage his health at home more effectively and reduce his risk of readmission. The availability of an effective digital patient solution also helped reduce his stay in the hospital and allow Norman to get home more rapidly.

Images of the patient care journey app

Additionally, to help reduce his risk of readmission even further (which is 23%), the hospital scheduled a Transition Care Management (TCM) visit for Norman within two days of his discharge. TCM visits have been shown to reduce readmissions by 50% as they provide proactive education and early complication identification. However, only 15-20% of TCM visits are actually conducted.

TCM visits are now reimbursed on average of $200-$275 per visit, helping to increase revenue.

43% of all hospitals were penalized for readmissions over the past 2 years and so preventing Norman’s readmission helps avoid Medicare penalties as well. 

Norman’s digital care plan also provided him with continual reminders for check-ins, surveys, and follow-up appointments, which also help prevent a costly readmission. He was able to schedule the recommended follow-up appointment with his personal care provider within 14 days and continued to recover at home.

The Tendo Patient Care Journey app will continue to support Norman’s long-term recovery by enabling easy scheduling of more follow-up appointments with his cardiologist,for an echocardiogram, and with other specialists and referrals as needed all within the app. These continuous notifications and reminders will keep Norman healthy and out of the hospital. About 20% of all referrals never result in a specialist visit.

Thanks to his digital care plan in the Tendo Patient Care Journey app, Norman was able to join a family vacation trip with the assurance that he was taking the necessary steps to manage his health. The hospital also avoided costly readmission penalties, and Norman’s positive outcome contributed to the hospital’s higher US News ranking in cardiology.

Norman’s story highlights the importance of using digital solutions to improve patient outcomes and reduce healthcare costs. By providing patients with proactive education, follow-ups, and remote monitoring tools, healthcare providers can help patients like Norman manage their health more effectively through risky transitions and reduce their risk of costly patient readmissions.

As healthcare continues to evolve, digital solutions will play an increasingly important role in improving patient outcomes and driving healthcare innovation forward.

I hope you enjoyed the first in this new series, Mike’s Metrics. Make sure you subscribe. You won’t want to miss my next blog where we will discover how a health system’s proactive approach to patient care and improved documentation not only resulted in better health outcomes for Robin, a high-risk patient but also positively impacted the health system’s revenue capture. Learn about the new interventions and ongoing care plan that helped Robin manage her chronic conditions. For more information on how Tendo does this visit Tendo Outreach. 

Mike Burton

Mike Burton

VP, Value Engineering

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