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Solving the Puzzle of Hospital Readmissions

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By Marcia Faller, PhD, RN, chief clinical officer and senior vice president, AMN Healthcare

I am a loyal customer to certain shops and businesses that I especially like, and they do what they can to encourage my repeat business; I am offered gold star memberships, frequent shopper discounts and more. But healthcare is different. In this business, we don’t want to see our customers return too soon or too often--and rightly so. Hospital readmission rates within 30 days of a patient’s release have become a key indicator of care quality and a major concern for legislators and healthcare leaders alike.

Unfortunately, the latest data shows that we still have a long way to go in reducing those preventable readmission rates. For instance:

  • A study published in JAMA in January found that 18% of hospitalizations resulted in at least one acute care encounter within 30 days of discharge; 40% of those patients returned to the emergency department, where the cost of care is usually at a premium;
  • Earlier this week, the Robert Wood Johnson Foundation (RWJF) published an aptly named report, The Revolving Door, that shows little progress has been made at reducing hospital readmissions for Medicare patients, and that different regions of the country have differing degrees of success (see interactive map).
  • The RWJF also reports that more than 4.4 million potentially preventable trips to the hospital add billions to the nation’s healthcare spending each year.

Not only do hospitals owe it to their patients to help keep them healthy and out of the hospital once they leave, but they can help themselves save a bundle by avoiding penalties for excessive 30-day readmission rates; the Centers for Medicare and Medicaid Services (CMS) estimates these penalties will cost hospitals $280 million this year and $25.7 billion during the next 10 years. 

So what can we do?

Some hospital readmissions are obviously unavoidable, depending on patient acuity and overall health, but for those that can be prevented, we have to work together to keep patients from coming back through that revolving door.  It will take teamwork among healthcare leaders, staff and patients alike to solve the puzzle.

Here are a just a few pieces to consider as part of a complete solution:

Improve quality care through better nurse staffing and work environments.  From the moment patients walk in the door, the quality of their care influences whether they might “bounce back” with problems within a short amount of time. A new study from the Center for Health Outcomes and Policy Research at the University of Pennsylvania has shown that nurse staffing and working conditions appear to have an impact on readmission rates due heart failure, acute myocardial infarction and pneumonia--the three conditions that CMS is tracking and penalizing hospitals for when readmission rates are excessive. In fact, the researchers found that each additional patient-per-nurse was associated with a 6%-9% percent increase in the odds of a patient’s readmission with 30 days.

Improve discharge instructions and patient understanding. In recent years, we’ve seen a shift in making discharge instructions more effective. As part of that movement, RWJF is promoting their Care About Your Care program this month, to explore what’s working as healthcare leaders partner with patients and frontline caregivers to improve care transitions and reduce avoidable hospital readmissions.  Downloadable patient materials are included, to make sure patients understand the care transition plan and are doing their part to avoid readmissions.

Improve care coordination among providers.  Hospitals can’t improve the readmission problem all by themselves, of course. New initiatives are helping build connections between hospitals and primary care physicians, pharmacists and other care providers in the community. Going forward, we should also see accountable care organizations (ACOs) becoming a bigger part of the solution. For now, the Institute for Healthcare Improvement looks at some case studies and provides a number of resources for reducing avoidable hospital readmissions, including tips for improving transitions to home health, skilled nursing facilities and primary care.

Yes, we have a long way to go, but I see encouraging signs of progress in this area. I also believe that the hospitals that make it a priority to reduce preventable readmissions and improve care across the board will see patients returning to their care--but it will be by choice and not because of a medical error during their stay, something that was overlooked at discharge or poor transitional care planning. 

And those healthier, more satisfied patients will be the most loyal customers and ambassadors a hospital could ever find.


More resources:
 
“Care About Your Care” materials from RWJF that you can download:
For providers: Reducing Avoidable Readmissions Through Better Care Transitions
For patients:  How to Avoid Being Readmitted to the Hospital; and Hospital Discharge Checklist and Care Transition Plan



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