Readmissions are a function of clinical, socio-economic and engagement risk. Members who are at high risk for multiple, clustered admissions (admissions and subsequent readmissions) typically have an undesirable disease trajectory as well as a history of engagement challenges, such as poor preventive behavior, sporadic visits to their doctor, excessive use to the ER, challenges with medication adherence, PCP switching, etc. Also, when probed (or when data on social determinants of health is available), these members have other socio-economic barriers, such as limited home care support, undesirable nutrition, poor health literacy, and so forth, which further compound and elevate their risk.
Because of this, proactive Home Health Care and Home Care are critical in reducing readmissions. Home Health Care and Home Care can deliver a variety of personalized and needed services, all geared towards reducing avoidable admissions and readmissions.