Reducing Hospital Readmissions with Chronic Care Management Software

meta image for Reducing Hospital Readmissions with Chronic Care Management Software

In 2011, the New England Journal of Medicine published a study that suggested the hospital readmission rate for heart failure was 20%. Over the years, as the number of chronic conditions has risen, the readmission rate has also increased.

Though an attempt has been made to reduce hospital readmissions, the complexities of patients’ health conditions have resulted in penalties for many hospitals under CMS’s Hospital Readmissions Reduction Program (HRRP).

However, recent advancements in healthcare technology have bridged the gap between care and empowered providers with data-driven practices for proactive patient care. The trend of hospital readmission is often observed in patients with two or more chronic conditions. And the best way to reduce hospital readmission using technology is to enroll patients in the CMS CCM program and leverage the power of chronic care management software.

Yes, you read that right! Chronic care management software can be your savior in reducing hospital admissions and navigating easily through the HRRP program.

So, without further ado, let’s explore the impact of CCM software on reducing hospital readmission.

The Reason for Hospital Readmission

Before getting into the technicalities of how the CCM software helps in reducing readmission, let’s first understand the reasons that lead to readmission in the first place.
So, understand that there can be many reasons why a patient can be readmitted to the hospital. Broadly classifying those reasons into three categories, here are the three main reasons:

1. Health Conditions & Complications

Patients often discover their underlying health conditions when they are discharged from the hospital; it is most commonly seen in patients suffering from chronic conditions like heart failure, COPD, or even diabetes.
Along with that, in case the patient has undergone any surgery, then any post-surgical complications can lead to further complications and, ultimately, readmission. At this time, the chances for the patient to catch new acute illnesses are high and can again result in hospital readmission.

2. Care Transitions & Follow-up Issues

Another reason that can lead to patient hospital readmission can be inadequate discharge planning or lack of follow-up proactive patient care after initial treatment. Along with that, incorrect medication can also contribute to readmission.

3. System-related Factors

The third and last group of reasons that contribute to hospital readmission are system-related issues like early discharge due to inefficient hospital management. Along with that, the communication gaps between healthcare providers and lack of coordinated care, which leads to fragmented care, can also lead to hospital readmission.

How Can Chronic Care Management Software Reduce Readmissions?

As a healthcare provider, you must know that every patient responds to the care services in different ways. Patients with higher immunity are often readmitted less than those with poor immunity. Hospital readmission of patients will always be there, but with CCM software, you address the patients who can easily avoid readmission and help them improve their health condition.
Here are some of the ways that can help you in reducing hospital readmission using CCM software:

1. Customized Personalized Care Plan

Chronic care management software is usually integrated with EHR systems, giving you access to the complete picture of a patient’s health history. With the medical history, along with the current readings, you can easily navigate through the patient’s condition and customize personalized care plans for them. To make this process easier, you can take the reference of the predefined care plans in the software and make customizations assessing the patient’s unique needs and preferences.

2. Medication Management, Adherence, & Patient Education

One of the major benefits of implementing CCM software in your healthcare practice is that it brings transparency to the care delivery process. Recording everything that is related to patient health can provide you with accurate insights into patient health.
With the help of the CCM software, you can easily manage the medication of the patient and check their adherence. Furthermore, in case of any mismanagement, you can increase patient adherence by proactively intervening and making required changes in the proactive patient care plan.
Along with that, the CCM software allows you to facilitate communication with the patients, which you can use to educate the patients about their condition to empower them with their condition. Better medication adherence and patient education can effectively reduce hospital readmission and improve patient health.

3. Timely Interventions & Remote Monitoring

CCM software also enables remote patient monitoring and gives you real-time access to patient data and vitals. Along with that, with further customizations in the CCM software, you can set alerts if a set threshold of patient vitals is crossed.
With such initiatives, you can easily intervene in the care plan and make adjustments to improve patient health. This is a significant improvement, and currently running CCM programs contribute to reducing hospital readmission.

4. Seamless Care & Coordination

CCM software is developed in a way that puts the patient at the center of the entire delivery process. This is achieved by facilitating communication and coordination between the dedicated care team. The seamless coordination helps the care team to be on the same page and work together to help the patient improve their health.
Such effective coordination between the healthcare providers is backed by data-based decision-making and effectively reduces patients’ hospital readmissions.

5. Addressing Social Determinants of Health

Another one of the major factors that contribute to hospital readmission is social determinants of health. These are usually the non-medical factors that influence health outcomes. Since the CCM software deals with data, it can integrate data from various sources to identify patients with potential SDOH challenges.
Here, you can leverage the power of the CCM software, and with proper coordination, you can help the patient connect with community resources and services to ensure they don’t worsen their health condition. Such initiatives can effectively help you overcome the SDOH challenges and reduce the chances of patients being readmitted to the hospital.

Future Trends in CCM Software to Reduce Hospital Readmission

Despite being someone who is not related to the technical field, you can agree that future innovations in healthcare technology advancements have been on the rise, and it is somewhere shaping the future of healthcare. One such application of technological advancement in data analytics that can help reduce hospital readmission rates is predictive modeling.
By using the models of data analytics, the CCM software can predict the possible health conditions of the patient beforehand. You can leverage this to accelerate your preventive care and intervene in time to reduce the chances of health escalation. Such initiatives, which involve interaction with advanced models like artificial intelligence and machine learning, can help in reducing the chances of hospital readmission. However, a few things to consider here are the evolving healthcare practices and policies that can hamper the process.


CCM software can help significantly reduce hospital readmission rates if used effectively and in the correct way. Moreover, as these digital means allow you to enhance your practice, you can leverage it to reduce the overall cost of healthcare for patients and you can use it to better manage your healthcare resources.

On the other hand, the rising hospital readmissions of chronically ill patients are alarming, and healthcare practices need to find other ways to reduce the burden of the already overburdened healthcare practices. For treating chronically ill patients, you can use CCM software with proper strategies to reduce hospital readmissions.

Frequently Asked Question’s

The cost of chronic care management software can vary, depending on features and practice size. While some options are budget-friendly, others can be more expensive. It’s crucial to weigh the software’s potential value in improving patient outcomes and practice efficiency against its cost.
The specific integration method depends on the software and your EHR system. Generally, it uses connections like APIs or data exchange to share patient information seamlessly between the software and your EHR, reducing data entry and improving workflow.
Yes, CCM software can reduce hospital readmissions by streamlining healthcare delivery and enabling remote monitoring of patient health conditions, with an option of providing preventive care in case the health condition escalates.

Several studies have shown positive results:

While beneficial, Chronic Care Management software can have drawbacks like:

  • Increased workload for staff: Learning, managing, and documenting software use can add to existing burdens.

  • Integration challenges: Challenges in integrating CCM software are compatibility issues between the software and existing EHR systems that can hinder data flow.

  • Privacy concerns: Ensuring patient data security and respecting privacy requires careful software selection and implementation.
Patient engagement in CCM is fostered by providing:
  • Easier communication: Secure messaging, appointment reminders, and educational resources.
  • Self-management tools: Track vitals, medications, and symptoms, promoting ownership of health.
  • Increased interaction: More frequent touchpoints with care team, leading to feeling valued and supported.
This combined approach empowers patients and fosters a sense of partnership in their healthcare journey, leading to higher satisfaction.

Leave a Reply

Your email address will not be published. Required fields are marked *

Table of Contents Toggle Table of Content

Generative AI whitepaper

Free Guide to Healthcare Software Adoption & Implementation

Download Now

Get Started with eCareMD

Free for 30 days, no credit card required

© 2024 eCareMD A product by Medarch Inc.