The Institute of Medicine reports that up to 75% of Medicare hospital readmissions are preventable.  

But you already know this. 

This means 1 in 5 Medicare enrollees readmitted, costing the US healthcare system $26 billion each year.

You see this firsthand in your practice, and we get it. 

It’s not that you don’t know how to prevent it. You want to make a difference, and you know you can.  

But in the real-world, you’re faced with frustrating challenges.

Your physicians can’t take any more work, RNs are in critical shortage, and you don’t have the bandwidth for implementing yet another set of clinical processes. 

That’s where CircleLink’s turn-key Chronic Care Management platform and services can help. In this article, you’ll discover how Toledo Clinic and Newark Beth Israel (of RWJBarnabas) overcame these same challenges while reducing i) inpatient costs 62% and ii) 30-day hospital readmissions 19%, respectively. All with zero budget and without new staff.

Your problems may seem insurmountable, but there’s an easier solution. 

In 2019 and 2020, respectively, Newark Beth Israel and The Toledo Clinic chose CircleLink Health to implement their Medicare’s Chronic Care Management (CCM) program. 

Here’s how they did it.

No new RNs or staff hired 

CircleLink provided all the RNs needed to implement CCM plus evidence-based transitional care interventions to reduce hospital readmissions.  

CircleLink RNs, upon a hospital discharge:

  • Perform a medication reconciliation to identify discrepancies so adverse drug reactions are prevented.
  • Use Motivational Interviewing strategies so patients complete a timely hospital follow-up visit.
  • Use the Teach-back Method to educate patients on red flag signs and symptoms, so patients know what to look out for, when to call the office, or seek urgent or emergency care.

Here’s an example of our RN’s triage system in action: 

No added work for providers 

Providers or designee get a brief message from a CircleLink RN only when necessary. 

Per below, CircleLink uses SBAR format for brevity (Situation, Background, Assessment, Recommendation).

No new clinical processes implemented

CircleLink RNs, every month during CCM calls:

  • Screen the patient for an ED visit or hospital discharge at each monthly patient encounter so transitional care interventions are initiated. CircleLink can also ingest real-time admissions/discharge notifications.
  • Complete an evidence-based Care Transition Note Template so all interventions are carried out to prevent a hospital readmission. 

Click here to get CircleLink’s evidence-based RN Readmission Prevention Checklist.

We can help 

These clinics reduced their 30-day hospital readmissions by 19% and inpatient costs by 62% by letting us do the work. 

“As a nurse, seeing the results from CircleLink Health’s care management platform on a day-to-day basis, you can’t speak more highly of what this means to the healthcare industry.”

Michelle Patten RN
Director of ACO and Clinical Operations, The Toledo Clinic

You don’t have to do this alone.

If you’d like to find out more about how we can help you reduce hospital readmissions and inpatient costs, Request a Free Strategic Conversation .

About the Author: Abigail Roaquin, BSN, RN is Circlelink Health’s Senior Nurse Management Advisor. Abigail has spent the last 25 years managing care for Medicare’s high-risk, high-cost population in various healthcare settings.