Preventing Hospital Readmissions: The First Test Case for Continuity of Care
Work on reducing hospital readmissions started with a focus on a better discharge process and has evolved to include more care and support to patients following discharge. Although there is no magic bullet model that every hospital can implement to minimize readmissions, research, combined with the approaches in hospitals with a track record of reducing readmissions, has identified key elements and a set of promising interventions.
- Hospital efforts to reduce readmissions have become more visible and important because the financial stakes — disincentives being incorporated into payment reform — are now high enough to be noticeable in the bottom line.
- Variability in rates across hospitals and regions of the country suggests that significant reductions are possible if practices in better performing hospitals are adopted more uniformly.
- Current measures employed in Medicare incentives target acute care hospitals and high-risk patients defined as those with heart failure, pneumonia, or an acute myocardial infarction. Any re-hospitalization to any hospital within 30 days, for any condition, is counted.
- Preventing readmissions is very challenging because so many community and patient factors contribute to the problem, many of them outside of the direct control of the hospital.
- However, research, combined with practices in hospitals with a track record of reducing readmissions, shows that comprehensive discharge planning and post-discharge care and support during the transition period reduces readmissions in high-risk patients.
- The next scope of work will be to achieve a formal connection with organized care management for every patient covered by this type of program.
- As more high-risk patients are covered by these programs, this will decrease the role of the hospital in providing post-discharge care and support, but formally link patients back to organizations accountable for ongoing care.
- Key elements of the resulting model will be organizing and operating transitional care as a process in its own right, laying out each patient’s transition and hand-off in a time-limited transition clinical pathway, and new uses of health IT in patient tracking and transition care planning.
The next phase of work will be to achieve a formal connection with organized care management for every patient covered by this type of program.
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