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12 Ways to Reduce Hospital Readmissions

Cheryl Clark, for HealthLeaders Media, December 27, 2010

2.Lengthen the Handoff Process
At every juncture in patient care process, especially discharge, have teams talk to each other about the patient.  And by the way, don't call them discharges. Call them "transitions."  Standardize them for a variety of providers, from hospital to rehabilitation facility to skilled nursing facility to home and back.

Boutwell says that "taking this person-centered approach shifts the concept from discharge, which is a moment in time and you're done with it, to a transition—a shared accountability. We need to make sure the receiving providers understand who this patient is, with a 360-degree view.

Jencks adds that "senders and receivers, for example hospital discharge planners and skilled nursing facility staff and home health" meet often enough so they can learn about the realities of the transitions they initiate and receive.

3.Provide Medication on Discharge
Send the patient home with 30-day medication supply, wrapped in packaging that clearly explains timing, dosage, frequency, etc. Some health centers with Medicaid patients may be trying this strategy, which is difficult for hospitals to do with Medicare patients because of distinctions between Part A and Part B payment. Still, for some high-risk populations, such as patients with congestive heart failure and those who have been readmitted before, it might be worth it for the hospital to absorb the cost.

4. Make a Follow-up Plan Before Discharge
Have hospital staff make follow-up appointments with patient's physician and don't discharge patient until this schedule is set up. A key is to make sure the patient has transportation to the physician's office, understands the importance of meeting that time frame, and following up with a phone call to the physician to assure that the visit was completed.

5. Telehealth
We couldn't find anyone using video monitors to communicate on a daily basis with the use of such software as Skype, for example, but some readmission experts say it's an interesting approach to keep up visual as well as verbal communication with patients, especially those that are high risk for readmission. 

On a more practical scale, Home Healthcare Partners in Dallas uses health coaches, intensive care clinicians, and wireless technology to record vital signs on a daily basis for about 2100 discharged Medicare fee-for-service beneficiaries for between 60 to 120 days. So far, they have done this for about 7,000 unduplicated patients in the last two years, for several hundred hospitals in Dallas and Louisiana, says HHP's CEO, Wayne Bazzle.

The target population for intense monitoring includes those with four or five co-morbidities and who have a primary diagnosis of congestive heart failure, chronic obstructive pulmonary disease, diabetes, Alzheimer's and hypertension.

Bazzle says that the effort involves phone calls of between five and 15 minutes, and is frequent enough with the same team "so we have their trust. We can help them stay out of the hospital if they're more truthful with us about what's going on, and if we see some deterioration, we can help them cope.  Normally it's a medication management issue, or they've become a little too relaxed with their diet."

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10 comments on "12 Ways to Reduce Hospital Readmissions"


Rick Bloemen (10/1/2012 at 11:52 AM)
I agree with Charlene Perrone and her comments that a big piece of the puzzle is during the discharge process. How much real information and true guidance are the families getting. Should they just be discharged to go home? Do they need in-home care to help monitor and administer care? Should they be sent to assisted living and if so, which one ? I have seen the practice over and over where a family is given "The Blue Book" and left to their own resources. And then we all wonder why there is a recurring readmission rate.In our business, we are a placement agency, we visit and rate the homes, work with in-home care agencies, meet and spend hours of time with the families doing assessments for care and budgets and then we tour the family to the different homes, to match the patient with the right care. Case managers do not have the time or resources to know which particular home would be the right choice. They do not visit each home and see the layouts for handicap accessability and function, diet control etc. I ask the question as did Charlene Parrone, that has an in-home care company, why not get out of the box and use other professionals to help? There are ways of screening out the non-legitimate companies. And I ask, what is better The system we have that is failing or to try a new approach? Or do we continue just handing out "The Blue Book" closing our eyes and hope that it works this time.

Charlene Perrone (8/2/2012 at 8:53 PM)
I find that there's something missing in our discussion regarding reducing hospital readmissions, and that's the non-medical home care component. Health Plans, hospitals, even physicians are looking for strategies to reduce readmission rates including hiring hospitalists, additional social workers, and nurses. But no-one is talking about the most cost-effective way to discharge patients appropriately and assist them in recuperating at home. Non-medical home care companies like mine have skilled, experienced caregivers who are well-versed in the discharge process, understand medications and dme, are able to monitor vital signs once the patient is home and under periodic home health care, and can support the patient every step of the way in his or her recuperation...at home. Home Instead Senior Care has even developed its own "hospital-to-home" evidence-based program called Returning Home, which is proven to have helped Medicare patients avoid hospital readmission within that critical 30-day period. The program includes a strategy for tracking patients so that hospitals and home health agencies can understand and improve the benefits of this vital collaboration. I realize that the low-income and minority populations are most at risk for hospital readmissions, and clearly that's a problem when it comes to non-medical home care, because right now the only way to cover our service is through private pay, long-term care insurance or veterans' benefits. That's why health care facilities and insurance plans need to be creative...and understand how important a piece of this collaborative puzzle we are. They need to figure out a way to commission or contract with companies like mine to assist their patients at discharge. As an example, a hospital or health plan might think of partnering with a legitimate company or group of companies like mine and paying for a certain number of hours with their patients to make sure the discharge papers are in order, that all dme is ordered, that a home health agency has been prescribed, and then to transport them, to make sure all meds are in place, to ensure they have adequate food and supplies, and to do follow-up to make sure the patient is following all discharge orders. Working together, we can reduce significantly the number of hospital readmissions; I know this for a fact. I just don't know if anyone in the health care industry is listening. C. Perrone

Janet Thurston MSN (1/21/2012 at 8:20 PM)
Everything written creates a safer, better experience for all patients. With this information now coming into realization, why is it so difficult to do? ie Pts go home with their meds understanding them, Dr follow up appts arranged. Pt questions answered. Why would a pt have to pay 100$ for a copy of their medical record? This is another shame. Dr to Dr / free Dr to Pt / fee