How Senior Care Communities Can Leverage Data to Reduce Rehospitalizations

Preventable rehospitalizations remain a top concern for senior care communities. Rehospitalizations place a significant burden on the healthcare system, increase costs, and often lead to poorer health outcomes and reduced quality of life for residents. While traditional strategies to reduce hospital readmissions remain important, senior care communities are increasingly turning to advanced analytics as a proactive tool to improve resident health and prevent avoidable readmissions.

Why Reducing Rehospitalizations Matters

Krithika Srivats, Senior Vice President, Clinical Practice and Product Innovation at Sagility

Hospital readmissions cost the U.S. healthcare system over $50 billion each year, yet many of these readmissions are preventable. “Readmissions may be attributable to quality of care during hospitalization, inadequate self-care or caregiver support post-discharge, lack of follow-through with appointments and treatment, and other factors,” explains Krithika Srivats, Senior Vice President, Clinical Practice and Product Innovation at Sagility.

In addition to the financial burden, hospitalizations can have a profound impact on seniors’ well-being. When older adults are hospitalized, their daily routines are often disrupted, leading to reduced mobility, skin breakdown, cognitive decline, and loss of independence. These consequences, Srivats notes, highlight the critical importance of preventing unnecessary rehospitalizations.

“In the United States, the average cost of hospitalization can be as high as $11,700 for seniors,” Srivats adds. This burden is intensified by the fact that nearly 95 percent of older adults live with at least one chronic illness, according to the National Council on Aging, contributing to higher hospitalization rates compared to the general population.

Factors Affecting Rehospitalization

Many factors can impact rehospitalization for seniors, such as older age, poor socio-economic status, malnutrition, multiple co-morbidities, and prolonged hospitalization. “There are also factors unique to each individual, such as cognitive decline, chronic conditions, fall history, current quality of care and related care coordination, social support, understanding their specific needs and adherence to the treatment plan, the length of the initial hospital stay, and discharge timing,” says Srivats.

She emphasizes the need for senior care communities to recognize and prioritize each resident’s discharge plan, noting that it is essential to have dedicated support in place to help residents follow through with their post-discharge care. “The community can use basic tracking tools to monitor changes and identify trends, enabling them to proactively develop an appropriate care plan,” she explains.

How Data-Driven Approaches Help Reduce Rehospitalizations

“Senior care communities are using data-driven approaches to reduce rehospitalization by leveraging data analytics to identify members who have the highest risk needs and who may be at the highest risk for readmission,” says Srivats. Communities can use resident health, medication, plan of care, and other data to analyze and identify readmission rate and risk factor trends. “Those trends can be leveraged to identify the areas where interventions could have the most impact,” she adds.

Additionally, communities can use data to personalize interventions and address each resident’s unique needs. The data can help communities coordinate care and improve communication. “Data can inform follow-up plans such as transportation to appointments, enable appropriate medication reconciliation, and reduce errors,” she says.

By leveraging a data-driven approach, senior care communities can deliver highly individualized care. Data can help communities identify each resident’s unique needs and determine an appropriate care plan. It also supports proactive management of chronic conditions, helping to prevent hospitalizations and reduce the risk of rehospitalization.

How to Implement Data-Driven Approaches to Reduce Hospitalization

Communities that aren’t currently using data analytics can get started by tracking key information about residents, such as frailty, cognitive or mood changes, changes in conditions or medications, fall history, or activities of daily living.

“To reduce rehospitalizations using data, a senior care community should start by focusing on identifying members at high risk, determining their priority needs, and implementing targeted interventions,” Srivats explains. “This could involve analyzing data from various sources like electronic health records; data such as claims, demographics, and social determinants of health; and surveys.”

She recommends communities use a platform that prioritizes data integration and predictive analytics. Communities should perform a brief assessment to determine or confirm a resident’s care needs, then use that insight to develop personalized care guidance.

There are some common misconceptions around the use of data analytics, including the belief that a community needs large amounts of data or a high-tech solution. “Asking the right questions in a simple survey of the population can yield a tremendous amount of information,” says Srivats. “The important thing is to ask the questions. What does our population need to avoid readmission to the hospital?”

Using Data to Support Better Health Outcomes

As technology advances, it offers new opportunities to improve resident health. By leveraging data, senior care communities can reduce rehospitalizations and enhance overall well-being. Increasingly, health systems are embracing whole-person care- focusing on individual needs, improving outcomes based on what matters most to each person, easing financial burdens, and supporting provider well-being.

“While data and cost are important elements, it’s equally important to see the value to the health and well-being of the individual,” says Srivats. In the case of senior care communities, reduced hospitalizations can improve health outcomes while also reducing interruptions to residents’ lives.

Paige Cerulli

Paige Cerulli is a contributing writer to i Advance Senior Care.