Reducing 30 day re-admissions by leveraging patient remote monitoring solution

Colorectal surgery (related to cancer) accounted for 27% of the total case mix for a large healthcare system
Colorectal surgery department noticed a steady increase in the number of patients returning back to the Emergency Room (ER) for non-urgent issues over a 24-month period
30-day readmission rates were significantly above the national average
Based on an initial internal assessment, the hospital management and colorectal surgery department hypothesized an issue with the patient discharge process
Established a cross-functional team to perform a root-cause analysis of the entire patient journey and flow
Mapped the entire patient journey and flow and identified a number of improvement opportunities

Designed a pilot study to test a new discharge process enabled by technology
Enrolled 97 patients, focusing on younger more tech savvy profile who were open to self-managing recovery during post-operative phase
Identified root-causes of readmissions into ER (over 78% non-emergency which could have been avoided if patients were better educated and informed during the discharge process)
Redesigned the discharge programme with a greater focus on patient self-management enabled by smart technology
Sent patients electronic reminders to help keep them on-track with recovery milestones
Established post-discharge daily check-ins to track stoma output, incision photos, pain levels, bowel function, etc.
Implemented algorithms to flag patient issues and automatically provide feedback to patients on how to self-manage or how and where to find relevant support
Developed intelligent notifications to automatically notify clinical team members if patient at risk
Designed and implemented a dashboard with real-time reports and analytics to help the care team understand a patient’s post-operative concerns, trajectory of recovery and ways to improve patient experience

Delivered a 72% reduction in 30-day re-admissions
Avoided 7 ER visits which were resolved through triage via telephone consultation or outpatient clinic
Improved patient satisfaction scores by 24% (compared to baseline pre-launch)
Based on the success of the programme, supported client to identify other surgical programmes to roll-out similar solution