Reduce Readmissions with Axiom's Help

A. 1/3 of unplanned readmissions occur within 1 month of discharge

B. 21% of preventable readmissions are patient factors

C. 4 criteria of inpatient care predict readmissions

1. Resolution of the main problem
2. Adequacy of post discharge destination
3. Stability of doses of therapy
4. Appropriate timing of the first follow-up visit Effects of Interventions A.

Readmission rates may be reduced by implementation to of pre-discharge reviews and improved follow-up after discharge B. Improved hospital and post-discharge care are associated with fewer readmissions C. Planned interventions for defined disorders show improvement in outcomes D. Benefits of interventions that combine clinical expertise with coordinated care in specific disorders E. Specific intervention features are

• Patient education
• Close follow-up
• Home monitoring
• Medication adjustment
• Regular communication with clinical experts

Internet Directed Care is a computerized program that combines proven effective post discharge interventions and a 5-week follow-up process. It uses the Internet for real-time medical record sharing between intra and inter disciplinary care providers.