Home sweet home! New program to reduce hospital re-admission rates and support customers at home

Medibank has launched a new service aimed at reducing hospital re-admissions and supporting customers to transition back home after a hospital stay.

‘After Hospital Home Care’ aims to drive a reduction in re-admission rates for patients recently discharged from hospital, in particular vulnerable groups. It has been designed for customers with a chronic health condition and other risk factors of hospital re-admission.

Medibank Chief Customer Officer Milosh Milisavljevic said the program aims to reduce re-admission by identifying and managing risks early, while supporting customers in their home.

“We understand the challenges people face after leaving the hospital, especially those at risk of being readmitted. We aim to provide additional care for customers, ensuring they receive the necessary support in the comfort of their own home,” said Mr Milisavljevic.

Medibank data shows each year around 120,000 customers are readmitted back into hospital within 90 days, with a large portion of these re-admissions coming within the first month and potentially avoidable.

These hospital re-admissions equate to around 300,000 bed days, highlighting the opportunity to reduce service demand and burden on the health system. Studies have shown that around one in seven hospital discharges in metropolitan Victoria results in an unplanned readmission within a month, and 10% of the readmissions occurred within a day of discharge.

“Vulnerable groups, such as older individuals, are disproportionately affected by unplanned re-admissions. Through this program, we aim to respond promptly to clinical deterioration, and identify other support needs that may arise during the recovery process. This will be provided to all customers at high risk of re-admission, regardless of the level of hospital cover they have with us,” he said.

“We launched the program around a month ago and we’ve already seen great results. We have had cases where readmissions and complications were avoided, including an acute case where a patient without support would have likely ended up in ICU.

“This is another example of our commitment to delivering innovative models of care that respond to the demand pressures and operating challenges across the healthcare system. If we can reduce re-admissions, we are taking pressure off the system, delivering care to patients where they are often most comfortable and providing customers with more value from their policy.”

After Hospital Home Care: Through a dedicated team of clinicians, including registered nurses, doctors, case coordinators and allied health professionals, key services available based on patient needs include:

• A nurse led initial in-home assessment and care plan
• Home visits by a nurse or allied health professional
• A visit from an Occupational Therapist to conduct a comprehensive falls risk or home assessment
• Where required, doctors are available to support patient care reducing the burden on the patient’s specialist
• A discharge summary from the program is shared with the GP to ensure continuity of care

All participants will co-design a Care Plan with a clinician that outlines their goals. The service will support members with self-management skills, medication adherence, safety in the home, understanding their health condition, and becoming active participants in their recovery.