There are many ways facilities can reduce hospital readmission rates while producing better health outcomes for patients and avoiding CMS reimbursement reductions. As the study “Reducing Hospital Readmission: Current Strategies and Future Directions,” published in the Annual Review of Medicine, aptly recommends, these strategies to reduce hospital readmission rates are best used in conjunction:
“The effect of interventions on readmission rates is related to the number of components implemented, whereas single-component interventions are unlikely to reduce readmissions significantly.”
1. – Focus on delivering quality care. Ensure that avoidable readmissions are not due to preventable errors on the part of your facility.
2. – Determine the cause of readmission. As RevCycleIntelligence states, “Understanding why a patient returns to the hospital after discharge is key to preventing readmissions and solving challenges of follow-up care.” Is the reason for readmission condition-related or are other factors at play (see #3)? Was the hospital readmission unnecessary and/or preventable?
3. – Screen for at-risk patients. Certain conditions, such as heart failure and pneumonia, have higher hospital readmission rates. Social factors that can affect hospital readmission include housing instability, tobacco use, alcohol/drug abuse, malnutrition and access to nutritious food, access to reliable transportation, health literacy, social support, language barriers, and psychiatric disease. Assistance may be best directed toward patients most vulnerable to readmission.
4. – Address no-show appointment issues to encourage at-risk patients to keep follow-up appointments that may lower their chances of hospital readmission.
5. – Improve the discharge process. Patients and their caregivers face much uncertainty upon leaving the safety net of the hospital environment. Take the time to thoroughly explain instructions for at-home care before they are discharged; follow up with phone calls or home visits to again confirm their understanding and allow them to ask questions.
6. – Take advantage of telehealth opportunities. Telehealth devices enable clinicians to monitor discharged patients’ health at home and can help reduce patients’ uncertainty about whether or not they need to revisit the hospital.
7. – Improve the transition process between facilities. Just as when a patient is moved from the hospital to home, moving from one facility to another can result in poor health outcomes and/or readmission if the transition does not go well. Follow one of the transitions of care models, many of which employ a care team to coordinate effective transitions and have been proven to reduce hospital readmission rates.
8. – Establish true interoperability. Better communication (in the form of successfully and consistently electronically sending, receiving, finding, and integrating/using data) is needed between facilities for proper care transition (and even across departments within the same facility). Without it, we risk patient safety and increase the likelihood of medical errors that affect readmission rates, such as adverse drug events due to inaccurate medication reconciliation.
“Effective interventions share certain features: having multiple components that span both inpatient and outpatient settings and delivery by dedicated transitional care personnel. New evidence suggests that the number of components in a care transitions intervention is significantly related to its effectiveness . . . which strengthens the argument for more robust interventions.”