Reducing Avoidable Readmissions with Patient Self-Management

Did you know that preventable hospital readmissions account for more than $17 billion in Medicare expenses each year?1

Most preventable readmissions are related to chronic conditions: infectious, non-infectious, or mental health conditions that have persisted over time. A patient’s chronic condition—for example, heart failure or chronic obstructive pulmonary disease (COPD)—might even be different from the initial reason for the hospitalization while still contributing to the rehospitalization.

For home health agencies, partnering with hospitals to help improve their avoidable readmission rates is a win-win-win. The hospital, the home health agency, and the patient all benefit when this partnership works.

One of the most effective ways to do so is to help patients better manage their chronic conditions. According to the World Health Organization (WHO), outcomes for patients with chronic conditions are significantly higher when patients (and their families) take an active role in their care.

Yet many patients with chronic diseases don’t have the skills or knowledge they need to effectively manage their condition, and often need a greater level of support between visits to their primary care provider than they currently receive. This is where the home health agency can provide a valuable service by helping to manage these conditions effectively. To do so, you must have a plan and encourage effective patient self-management.

Evidence-based models for chronic condition management

Adopting an evidence-based model for chronic condition management is a good way to ensure that you’re following best practices that will help your patients achieve the best possible outcomes. Some examples of good evidence-based models are:

  • Chronic Care Model (CCM), designed to help practices improve patient outcomes through six interrelated system changes.
  • Innovative Care for Chronic Conditions (ICCC), developed by WHO, a flexible and comprehensive model to build or redesign health systems in alignment with local resources and demands.
  • Chronic Disease Self-Management Program (CDSMP), developed by researchers at Stanford University, focused on helping patients learn to self-manage their chronic conditions.
  • Community-Based Care Transitions Model (CBTM), developed by home care providers to equip clinicians with additional skills for managing chronic conditions and to address gaps in care transitions for chronic condition patients.
  • The role of patient-centered care

    The primary role of the home health agency in chronic condition management should be to support patients’ efforts at effective self-management, which can help patients adhere to care plans in ways that minimize complications, symptoms, and lack of mobility associated with chronic conditions. That’s why it’s important to train your staff on how to support patients in self-management, as well as on techniques for motivating patients to implement self-management strategies on a consistent daily basis.

    The most effective way to support patients in their self-management is to take a patient-centered approach that respects and responds to individual patient preferences, needs, and values, and ensures that those values help inform all clinical decisions. This might include:

  • Compassionate care, which involves listening, empathizing, and respecting the dignity and individual needs of a patient.
  • Collaborative involvement between a multidisciplinary healthcare team, including the primary care physician, the patient, and the patient’s family.
  • Identifying and mitigating barriers to patient progress.
  • Well-planned visits that focus on prevention and care management.
  • Involving patients in goal setting.
  • Customized education and skills training.
  • Attention to health literacy, language, and culture.
  • Referrals to community-based resources.
  • Frequent follow-up.
  • Home health team members can empower patients to better manage their chronic conditions by making good daily decisions in lifestyle areas such as diet, exercise, taking medications, navigating relationships, and interacting with healthcare providers.

    Reducing the burden of chronic conditions

    An evidence-based process for chronic condition management will provide value to your patients and hospital partners. Through collaboration, coordination, and engagement, we are able to influence better outcomes, reduce readmissions, and, ultimately, reduce the burden of chronic conditions on the healthcare system.


    1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418-28.10.1056/NEJMsa0803563