Reducing Hospital Readmissions

Summary / Explanation

Introduction

A hospital readmission is when a patient discharged from the hospital is readmitted within a specified time frame. Various time frames have been used, but the most common are 30-day (Medicare definition), 90-day, and 1-year readmissions. The first hospital stay is termed "index admission," and the subsequent hospital admission is termed "readmission." Hospital readmissions can pose significant challenges for both healthcare providers and patients. Moya Woodside first mentioned hospital readmission in psychiatric patients in 1953.[1][2] Since then, hospital readmission has gained more recognition in medical literature, leading to rising healthcare costs, accounting for billions in costs.[3] This has put a substantial financial burden on the healthcare system. From a statistical perspective, approximately 20% of Medicare beneficiaries experienced readmission within a span of 30 days.[3]

In 2010, hospital readmission rates were formally included in reimbursement decisions by the Centers for Medicare and Medicaid Services (CMS) formally included as part of the Affordable Care Act (ACA). This legislature resulted in the CMS initiating penalties for healthcare systems that exhibited relatively higher rates of readmissions through the Hospital Readmission Reduction Program (HRRP). In 2013, the HRRP was officially introduced and applied to all hospitals except psychiatric, rehabilitation, pediatric, cancer, and critical access hospitals. In recent years, healthcare organizations have actively worked to decrease readmissions by implementing diverse strategies. The readmission rates have been increasingly utilized as a quality benchmark for health systems and an outcome measure in health services research.[4] It has been further explored in health services outcomes research about the patient demographics, frequency, regional differences, their causes, and various methods and models to prevent them.[5][6] 

When patients are readmitted shortly after their initial hospital stay, it indicates suboptimal quality of care, inadequate patient education, and challenges transitioning from hospital to home. In the last decade, more programs have been introduced to reduce hospital readmissions, as this has become a top priority in U.S. healthcare reform. These have significantly reduced the readmission rates to about 15% from 20% in myocardial infarction (AMI) patients.[7] Further studies have shown that readmission rates declined from 21.5% to 17.8% for targeted conditions and 15.3% to 13.1 % for non-targeted conditions in the time period from 2007 to 2015 (per Medicare).[8] In this article, we will delve into the importance of reducing hospital readmissions, the underlying causes of readmissions, and the strategies used to tackle this crucial challenge.

The Significance of Hospital Readmission Reduction

Reducing hospital readmission is crucial for several reasons, as shown below.

Patient Well-Being

• Emotional and physical impact: Frequent hospital readmissions can emotionally drain patients and their families. The stress, uncertainty, and disruption caused by repeated hospital visits can be emotionally draining. Physically, patients may face complications related to their health conditions or treatments.

• Confidence in the healthcare system: Multiple readmissions can erode patients' trust in the healthcare system. They may question the quality of care received during their initial hospital stay and wonder why they need to return so soon.

Financial Implications

• Cost to patients: Hospital readmissions often result in out-of-pocket expenses for patients. Copayments, deductibles, and other costs accumulate with each admission.

• Healthcare institutions' costs: Readmissions strain healthcare resources, including hospital beds, staff time, and medical supplies. Hospitals must allocate additional resources to manage these cases.

• Overall Cost of Care: The cumulative cost of readmissions contributes significantly to healthcare expenditures. Reducing readmissions can mitigate this financial burden.

Resource Optimization

• Efficient use of resources: When patients are readmitted, it diverts resources from other patients who also need care. By minimizing readmissions, we optimize resource allocation.

• Focus on preventive measures: Efforts to reduce readmissions encourage healthcare providers to focus on preventive strategies. This includes better discharge planning, patient education, and post-discharge follow-up.

Reasons Behind Readmissions

Understanding the root causes of hospital readmissions is crucial for developing effective reduction strategies. While numerous readmissions are not preventable, they may represent disease progression, a separate problem unrelated to admission, or difficulties in adhering to the discharge plan (such as being unable to fill prescriptions). Some readmissions are likely preventable; a systematic review of 34 studies revealed that the median proportion of preventable readmissions was 27 percent, ranging from 5 to 79 percent.[9]  Further, an observational study of 1000 patients readmitted within 30 days of discharge revealed that around 27 percent of these readmissions were considered potentially preventable, defined as those with more than a 50% chance that readmission could have been prevented.[10]  The most common preventable factors were emergency department decision-making regarding readmission, failure to relay important information to outpatient providers, discharge of patients too soon, and lack of goals of care discussions among patients with serious illnesses. Additionally, a study using Medicare data for over 200,000 patients showed that initial admission rates played a more significant role in the regional variation of readmission rates than other factors such as case mix, hospital size, discharge planning, or the number of specialist physicians or primary care.[11] Several common factors increase the likelihood of readmission that may be modifiable, especially those related to clinician or system-level issues. Such factors include:

During Hospital: 

• Inadequate handoffs: Poor information transfer from providers to providers, particularly hospital-based to primary care providers. A meta-analysis found that only 12% and 34% of discharge summaries were received by aftercare providers at the time of the first appointment following hospitalization.[12] Furthermore, the documentation often had errors, such as medication adjustment, pending tests, follow-up plans, referrals, etc., that can contribute to readmissions. 

• Medication-related issues: Newly prescribed medications or altered dosages during or after hospital discharge can react or cause adverse drug events that can prompt readmissions. Polypharmacy is another risk factor that contributes to readmissions.[13] 

• Higher-risk patients: Certain readmission risk factors vary and can be clinical (such as high-risk medication use, multiple chronic conditions, specific diseases) or demographic/logistical (like prior hospitalization, race, low health literacy, limited social network, lower socioeconomic status, and discharge against medical advice).[14][15]

• Complications in the hospital: Some patients may develop nosocomial infections, pressure ulcers, falls, and procedure complications during or shortly after a hospital stay. These events can increase the rates of readmissions.

On Discharge: 

• Therapeutic errors: Medication reconciliation errors can lead to duplicating medications or improper dosages or frequency of medications, prompting early readmission. One study estimated that about 20% of patients experience adverse events after discharge, with medication-related issues being the most common.[16] Roughly two-thirds of these adverse events were found to be either preventable or could have been mitigated. 

• Premature discharge: Discharging a patient prematurely for various reasons, like cost-effectiveness or prevention of hospital-acquired infections, can predispose the patient to another hospital visit sooner than expected.

After Discharge: 

• Insufficient, delayed, or absent follow-up: Only half of the Medicare beneficiaries who needed to be readmitted within 30 days of discharge had a follow-up visit with a clinician.[3]

• Inadequate post-discharge care: Patients may not receive appropriate follow-up care, such as medication management, physical therapy, or home healthcare. This can worsen their condition and necessitate a return to the hospital.

• Medication mismanagement: Patients may misunderstand or forget medication instructions, leading to incorrect dosages or missed doses. This can result in symptom exacerbation or complications, prompting readmission.

• Inadequate communication and coordination: Poor communication between healthcare providers, insufficient care coordination, and the lack of a clear transition plan from hospital to home can result in readmission. Also, a language barrier amongst healthcare providers, staff, and patients can lead to further misinformation, as some things are just "lost in translation."

• Lack of patient education: Many readmissions occur because patients do not fully understand their conditions or how to manage them. Inadequate patient education can lead to non-compliance with treatment plans and follow-up care.

• Social determinants of health: Patients' social and economic circumstances can impact their ability to adhere to treatment recommendations. Factors such as transportation issues, food insecurity, and housing instability can increase the risk of readmission.

Strategies for Reducing Hospital Readmissions

Healthcare institutions have been implementing various strategies to reduce hospital readmissions, with a focus on re-engineering the discharge process by improving patient care and education, enhancing communication and coordination, and addressing social determinants of health and arrangements for prompt follow-up.[17] Here are some key strategies:

• Care transition programs: Hospitals can implement transition programs that help patients smoothly transition from inpatient to outpatient care. These programs often involve providing patients with a written care plan, coordinating follow-up appointments, and educating them about their condition and self-care.[18] An excellent example of this is a study that evaluated the Care Transitions Intervention (CTI) program in which older patients were paired with a discharge nurse transition coach.[18] The nurse (transition coach) helped the patient, family member, or caregiver and encouraged timely follow-ups, self-care, and patient education and awareness about what to do if a problem arises. The transition coach saw the patient before discharge, then at home 2 to 3 days post-discharge, followed by at least three telephone calls up to the first 28 days after discharge. As a result of this program, a significant reduction in 30- and 90-day readmission rates (8.3 versus 11.9 percent and 16.7 versus 22.5 percent, respectively) led to a cost-save of $500 per case.

• Medication reconciliation: Hospitals should conduct medication reconciliation before patients are discharged to ensure that patients are aware of their medications, understand their dosages, and can manage their medications effectively. This can be crucial in preventing medication-related readmissions.[19][20][19]

• Post-discharge follow-up: Healthcare institutions can schedule post-discharge follow-up appointments to monitor patients' progress and address any emerging issues. Telehealth services and home healthcare can also be utilized to provide remote care and support.[21][22]

• Patient education: Comprehensive patient education is important to ensure patients understand their conditions, treatment plans, and the importance of adhering to recommendations. Transparent, accessible educational materials and resources should be provided to patients and their families.

• Care coordination: Improved communication and coordination between healthcare providers can help ensure patients receive continuous and comprehensive care. Electronic health records and secure communication systems can facilitate information sharing among healthcare teams.

• Addressing social determinants of health: Hospitals can work with community organizations and social workers to assess and address patients' social determinants of health. Connecting patients with resources to address transportation, housing, and food security can help prevent readmissions.

• Quality improvement initiatives: Healthcare institutions can implement continuous quality improvement programs to identify and address specific areas of concern related to readmissions. By analyzing data, hospitals can tailor their approaches to reduce readmissions for specific conditions or patient populations.[23] A randomized controlled trial at a large academic hospital assessed 749 patients and explored the efficacy of a multidisciplinary team in minimizing readmissions and emergency department visits.[24] The team comprised a nurse for discharge planning, a pharmacist responsible for post-discharge follow-up calls, pre-scheduled follow-up appointments, medication reconciliation, and a discharge instruction booklet tailored for low literacy. The rate of post-discharge hospital utilization was 31 percent for the intervention group compared with 44 percent for the control group. Patients in the intervention group were also more likely to follow up with their primary care provider.[25]

• Engaging patients and families: Actively involving patients and their families in the care planning can improve their understanding and motivation to follow recommended treatments and self-care measures. 

Conclusion

Reducing hospital readmissions is not only a healthcare imperative but also a financial necessity. By addressing the root causes of readmissions and implementing strategies that focus on patient education, care coordination, and addressing social determinants of health, healthcare institutions can make significant strides in reducing readmissions and improving patient outcomes. Achieving a sustainable reduction in readmissions requires a holistic and patient-centered approach considering the multifaceted factors contributing to this issue. Ultimately, the success of these efforts not only benefits individual patients but also leads to the overall cost-effectiveness and efficiency of the healthcare system.