Post-Discharge Interventions to Prevent Readmissions in Value-Based Kidney Care

Interwell Health has launched two new post-discharge programs to reduce hospital readmissions

February 14, 2024
5 minutes
Side view of woman doctor with male patient

A recent data analysis by Interwell Health suggests that a timely follow-up with a nephrologist after discharge from the hospital can significantly reduce readmissions for people living with chronic kidney disease (CKD).

Interwell examined the outcomes of more than 11,000 individuals with late-stage CKD who were hospitalized and discharged. The review compared those who visited a nephrologist within 14 days of discharge to a similar patient group that did not have a timely follow-up visit. Patients who saw their nephrologist in the first two weeks after leaving the hospital were almost 25 percent less likely to be readmitted.

“Sometimes getting a patient back to see us within a week or two after a discharge is challenging, but now we know it’s really important,” said Tony Brown, DO, a nephrologist at Nephrology and Hypertension Associates in New Jersey, who was encouraged by the strength of Interwell’s findings. “The key is being able to identify these patients in a timely manner and having the resources to reach back out to them.”

Partnering with physicians to launch new post-discharge programs

As a result of this research, Interwell launched two new post-discharge programs in 2023 to further reduce readmissions. One rapid outreach effort uses a team of care coordinators to directly contact patients recently released from the hospital to schedule follow-up appointments. The second effort is powered by data from Acumen Epic Connect, the most-adopted nephrology-specific electronic health record (EHR), to identify discharges and encourage follow-up visits by the nephrology practice.

"There is excitement at the physician level,” said Leslly Matznick, director of healthcare operations at Interwell who helped launch the rapid outreach program. “They can see the statistics and understand why it's so important for patients and their practice.”

Physicians also see how reducing readmissions lowers the total cost of care. An analysis by the Agency for Healthcare Research and Quality showed that the average cost of a readmission was $16,300 in 2020, 12.4 percent higher than the cost of the original, or “index” admission.1 An earlier analysis showed that chronic kidney disease had the fifth highest rate of 30-day all-cause adult hospital readmissions compared to other diseases.

“Sometimes getting a patient back to see us within a week or two after a discharge is challenging, but now we know it’s really important.”

Brown says these efforts to drive down readmissions are beginning to impact patient health and cost of care across practices in the Interwell network. In just the first two quarters of 2023, his practice reduced the cost per patient by 12.5 percent for more than 700 patients in a value-based care program.

Building a team for rapid outreach after hospitalization

As one of many care coordinators working in this new program, Muna Al Sodani calls patients just one to two days after discharge from the hospital. She often makes more than 30 calls a day to coordinate with physician practices, follow up with patients, or book new appointments.

“Our patients really appreciate it when you reach out and check on them after being hospitalized,” said Sodani. “All they need is that touch, that call, to ask, ‘how are you doing’? They can tell if you seriously care about them.”

Many nephrology practices will not know their patient has been discharged from a hospital stay until informed by the Interwell care team. The rapid outreach programs work with nephrology practices both outside and inside the Interwell network, which now includes more than 180 practices and almost 1,800 physicians.

Sodani informs the nephrology practice of this important information and also works with them to schedule the patient’s next appointment. It is a process that must be tailored to the preferences of each practice to be most successful.

“Most nephrology practices I speak with are supportive of this program and understand why it's important,” said Sodani. “It really impacts the members directly and nobody wants to see them in the hospital again.”

Sodani and Brown note that one of the most significant concerns for patients after discharge is medication management. Prescriptions are often removed or added during a hospital stay.

“The hospitalists do a good job, but sometimes they discharge a patient with a new medication that can conflict with other drugs or be toxic to the kidney,” said Brown. “Managing kidney disease is quite complex, which is why it’s important we see them quickly after a discharge.”

Using Acumen Epic Connect to identify discharges and encourage follow-ups

Interwell has also launched a separate program with Interwell-aligned nephrology practices that use Acumen Epic Connect. Timely discharge notifications are fed directly into the EHR through the combination of Epic's powerful Care Everywhere platform, Interwell's national and regional health information exchange vendor partnerships, and Acumen's hospital rounding tool.

A custom dashboard was also built specifically for nephrologists to administer this program. The dashboard alerts practices to the time since discharge, providing clear insight into whether a patient has been seen within the 14-day window.

“The benefit of these programs is being able to detect recent discharges quickly, as claims data does not provide timely information necessary to make these interventions,” said Terry Ketchersid, MD, a senior vice president in Interwell’s medical office who helped design the post-discharge program leveraging Acumen data. “These practices have agreed to share their data with us so we can closely monitor performance and help them succeed in this important initiative.”

Brown’s practice is using Acumen to improve patient care, including to help reduce readmissions, better manage comorbidities, and manage risk in new value-based care agreements with government and private payers. An Interwell renal care coordinator is also embedded in their practice to help drive these initiatives forward.

"Interwell has been such an advantageous partner in multiple ways by constantly going over areas we can improve or where we can do better,” said Brown. “It's a real partnership and we trust them.”

Expanding program and driving results

Interwell is expanding both post-discharge programs so that even more patients in value-based care arrangements can benefit from these initiatives. The goal is to follow up with every patient discharged from the hospital within just a few days and have them seen in the two-week window, which should significantly lower readmission rates. 




  1. Characteristics Of 30-Day All-Cause Hospital Readmissions, 2016-2020. Statistical Brief #304. Agency for Healthcare Research and Quality
  2. Overview of Clinical Conditions with Frequent and Costly Hospital Readmissions by Payer, 2018. Statistical Brief #278. Agency for Healthcare Research and Quality