Feature August 25, 2021 John Bernot, MD

Enhanced recovery challenges: Reduce costly readmissions by identifying post-op patient risk factors

Learn how to uncover and manage the post-op patient risk factors that are driving up readmissions and reducing profit margins.

Patient risk factors

The average readmission cost for a total knee replacement (TKR) patient within the first 30 days is $11,9041 and climbing every year. 

While alternative payment models such as the CMMI Comprehensive Care for Joint Replacement (CJR) program incentivize providers to reduce readmissions, they do not provide any tools for managing the underlying issues that lead to readmissions.

Rather, it is left to the care team to identify patient risk factors and proactively address them. 

Following, you will learn:

  • How to identify post-op red flags
  • Tips for efficiently managing risk factors 
  • Benefits of proactively addressing risk factors

Uncovering post-op patient risk factors: What to look for 

Payment programs and reimbursement models focused on reducing readmissions, including requirements to gather patient-reported outcomes (PROs) 9 to 12 months after surgery, create new opportunities for increased patient engagement

The first step is to identify the risk factors that increase the likelihood of readmission. These factors are often related to the social determinants of health (SDOH) and may not be readily found in the patient’s EHR.

Here are seven post-op red flags to look for:

  1. Social isolation
  2. Uncontrolled pain and pain-related anxiety
  3. Malnutrition, high A1C levels, and other chronic illnesses
  4. Minimal compliance with discharge instructions
  5. Poor incision monitoring
  6. Improper medication adherence
  7. Low health literacy

Trusted two-way communication between the patient and the care team is essential to uncovering these red flags. 

Preparing your patients for what to expect after surgery by providing them with educational materials and proactive optimization strategies is one way to get the conversation started. 

However, lacking the in-person appointments for relationship-building, surgeons and their care teams can adopt an easy-to-use digital health app to: 

  • Answer patients’ questions
  • Gauge patients’ understanding of discharge instructions
  • Distribute educational materials and care plans
  • Send reminders to check incisions and take medications
  • Rate pain and anxiety levels
  • Gain insight into social isolation and other SDOH factors

3 tips for managing post-op patient risk factors

After you know what red flags to look for, the second step is to have protocols in place to address them. 

Here are three tips to effectively manage post-op patient risk factors: 

  1. Establish clinical workflows to alert appropriate members of the care team when a patient risk factor is identified.
  2. Create detailed care plans for each red flag that can be customized to meet the patient’s specific needs.
  3. Have the digital health tools in place to communicate the course correction effectively.  

The financial benefits of being proactive 

Having digital health tools to facilitate open communication with patients after surgery is essential to any readmission reduction strategy.

With the right tools, you can:

  • Identify high-risk patients 
  • Avoid infections and other complications that often lead to readmissions
  • Monitor for social isolation and other hidden factors that impact recovery 

Start maximizing profit margins for surgical procedures and make Ayva part of your strategy to reduce readmissions.

Contact Us

Share article

Media Contacts

Shane Andreasen

Bravado Health


Bravado Health Media Line


(561) 805-5935