Reducing hospital readmissions is one of the most pressing challenges in healthcare today. High readmission rates strain hospital resources, compromise patient outcomes and negatively affect critical metrics such as patient satisfaction and safety. Vanderbilt University Hospital tackled this issue head-on with its Discharge Care Center (DCC), developing personalized care with post-discharge communication.
Vanderbilt’s latest study highlighted the impact of Artera for streamlining post-discharge communication, empowering care teams and delivering measurable results. This blog will explore the key elements of Vanderbilt’s initiative, highlighting why post-discharge communication is vital, how the DCC utilized Artera and the outcomes that followed. By the end, you’ll gain actionable insights into how your healthcare organization can adopt these strategies to improve both clinical outcomes and operational efficiency.
About the Study
Vanderbilt University Hospital’s Discharge Care Center (DCC) was born from a desire to bridge the critical gap between inpatient care and at-home recovery. Hospitals frequently encounter unplanned hospital readmissions, often caused by breakdowns in communication and follow-up after discharge. The DCC was designed as a solution to this, leveraging both specialized personnel and technology to address patients’ post-discharge needs effectively.
Key elements of the DCC initiative included a multidisciplinary care coordination team, automated risk-based patient monitoring and a post-discharge communication strategy tailored to the diverse needs of Vanderbilt’s patient population. Over two years (October 2021 – October 2023), the DCC provided follow-up care for more than 80,000 discharges and intervened in over 57,000 critical cases. With a sustained reduction in the hospital’s 30-day readmission rates—from 10.6% to 9.9%—the program proved to be a resounding success.
But what truly set Vanderbilt apart was its emphasis on leveraging Artera, a robust patient communication platform, for post-discharge communication. Artera made these outcomes possible by automating outreach, providing real-time insights and enabling seamless communication with patients, all while reducing operational burdens on hospital staff.
The Importance of Post-Discharge Communication
Discharge is a pivotal moment in the patient care continuum. For patients, it marks the shift from the structured support of a hospital stay to self-directed care at home. For hospitals, it represents an opportunity to ensure continuity of care and minimize preventable readmissions.
Despite the critical nature of clear, effective communication with patients post-discharge, it is often overlooked. Here are some ways post-discharge communication can bridge the gaps:
- Enhancing Patient Safety: Automated follow-ups help identify issues like medication errors, unmanaged symptoms or unfulfilled home-care needs before they escalate.
- Empowering Patients: Patients are more likely to adhere to care plans when they feel supported. Timely reminders about medications, follow-up appointments and lifestyle changes can make a measurable difference.
- Reducing Operational Costs: Avoiding readmissions not only spares patients the physical and mental burden of returning to the hospital, but also significantly reduces financial penalties for hospitals under value-based care models.
How Vanderbilt Used Artera for Post-Discharge Communication
Artera was the technological backbone supporting Vanderbilt’s Discharge Care Center for automated communication. In the study, the automated texting and calling continued throughout the first 30 days post-discharge, with standard content for all patients. Here’s how the platform powered post-discharge communication:
- Day 0: The initial automated text message is sent 1 hour after the discharge order is placed. For patients indicating a preference for a telephone call, the first call is placed the following day.
- Day 1 Post-Discharge: Receive a text message about medications
- Day 2 Post-Discharge: Receive a message inquiring about outpatient follow-up
- Day 3 Post-Discharge: Receive a message verifying receipt of any clinician-ordered durable medical equipment or home health services.
To monitor for new or worsening symptoms, the text messages continued every 2 to 3 days for the first 15 days, followed by every 5 days, for a total of 12 messages across 30 days. If the patient responded to the texts or calls indicating they had a need, two-way communication was initiated. Depending on the type and complexity of help needed, concerns were then addressed by the Triage Team or the Care Coordination Team.
Key Findings from Vanderbilt’s Study
The Discharge Care Center (DCC) at Vanderbilt University Hospital, enhanced by Artera’s automated communication tools, addressed over 80,000 hospital discharges during its first two years. This initiative reduced the hospital’s 30-day unplanned readmission rate from 10.6% to 9.9%, representing a 6.6% relative reduction in just two years. With an average readmission cost of $15,200 per occurrence, this reduction translated into avoiding approximately $2.9 million annually in healthcare costs.
According to the authors of the study, “Applying the readmission rate reduction (10.6% to 9.9%) to our postintervention population, we estimate that there was an average of 197 fewer readmissions per year at our hospital during this 2-year period, compared with the period before the program rollout.”
Artera played a central role in this success. Its automated messaging capabilities allowed for timely and personalized follow-up with patients, enabling proactive outreach and rapid responses to patient needs. Over 97% of discharged patients remained engaged with the DCC program beyond the first message, with 73% actively participating throughout the entire 30-day period. These interactions fostered trust, improved adherence to care plans and flagged potential complications early.
Here are other standout metrics from the study:
- 57,352 clinically relevant interventions were carried out post-discharge.
- 29% of discharges required intervention, with higher rates for patients categorized as high-risk.
- The program handled more than 3,200 patients at any given time, highlighting its scalability and efficiency.
Through collaborations between DCC’s Triage Team and Care Coordination Team, Vanderbilt managed to prioritize resources effectively and provide personalized, round-the-clock care to discharged patients.
A Scalable Model for Healthcare Organizations
Vanderbilt’s implementation demonstrates how a combination of automation and human intervention can create a robust post-discharge care strategy. Here are some elements other hospitals can emulate:
1. Automation with Personalization
By automating routine follow-ups, Vanderbilt allowed clinical staff to concentrate on complex cases requiring hands-on care. Text message prompts about medication adherence or follow-up visits served as low-cost yet high-impact interventions.
2. Risk-Stratified Care
Using a predictive algorithm, Vanderbilt identified high-risk patients who received additional attention, such as personalized calls. This targeted approach ensured that resources were allocated efficiently, maximizing the DCC’s impact.
3. Interdisciplinary Collaboration
The program’s Triage Team (RNs responding to immediate patient concerns) and Care Coordination Team (pharmacists and social workers addressing deeper needs) worked seamlessly to prevent gaps in care.
4. Continuous Feedback Loops
Regular quality review meetings allowed staff to adapt the program dynamically based on identified gaps or patient feedback, ensuring continuous improvement.
Bringing It All Together
Vanderbilt’s use of Artera demonstrates that when healthcare organizations prioritize post-discharge communication, the results are profound. Lower readmission rates, enhanced patient safety and improved satisfaction aren’t just achievable––they’re actionable goals for hospitals willing to innovate. To read the full Vanderbilt University Hospital study, check it out here.
If your organization is grappling with high readmissions or patient satisfaction challenges, adopting a similar strategy could be transformational. By leveraging technology for personalized, proactive care, hospitals can redefine what it means to support patients beyond the bedside.
Are you ready to take the first step in improving post-discharge outcomes? Explore how automated communication tools like Artera Care Navigator can complement your existing operations and set a new standard of care.
