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5 Questions to Determine Readmission Rate Effectiveness

Joan Moss, RN, MSN, Senior Vice President, Sg2, for HealthLeaders Media, June 30, 2011

AMI patients need to see their cardiologist within 7 days after discharge and should be enrolled in cardiac rehabilitation. Readmission rates for pneumonia patients, who typically return with unresolved pneumonia or COPD, vary significantly by hospital, ranging from 15% to more than 22%. Mortality rates are even more striking, ranging from 6.7% to nearly 21%. It is important to treat the elderly and immunocompromised patients further upstream with vaccines, and timely blood cultures and antibiotic treatments should begin within 2 to 4 hours of diagnosis. The majority of all hospital readmissions are usually due to the original admission or related conditions, but the reasons vary more widely between 7, 14 and 30 days postdischarge.

Question 4: What post-acute referral locations create our greatest readmission risks?
Regardless of whether or not a hospital or health system owns a post-acute care site, it will be held accountable for readmissions from that site. Readmission rates for post-acute care providers differ, with skilled nursing facilities and home health care typically showing the highest rates of inpatient readmission. Clinical leaders should meet with their post-acute care providers to discuss what kinds of patients they are seeing, how ill those patients are and how transitions can be improved. Post-acute data by disease and site of care need to be understood and managed with all stakeholders brought into the process.

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3 comments on "5 Questions to Determine Readmission Rate Effectiveness"


Solomon J. Zak, M.D. (7/7/2011 at 9:39 AM)
Most authorities fail to understand the effectiveness of discharge planning. One needs to [INVALID] computer screens that are specific for comprehensive discharge planning for each at risk diagnosis (and co-morbidity). At the time of discharge, All attending physicians, including the Primary Care Physician and discharge staff must complete these screens which must be precisely diagnostically correct retrospectively and prospectively. For example, if a 67 year old member has not had (vaccine) pneumococcal immunization, that should be given before discharge. Importantly the Primary Care Physician must be identified as the RESPONSIBLE physician, whether the patient is being treated by a Cardiologist, Oncologist, Surgeon, etc. Issue: There must be a SINGLE accountable physician identified and at risk.

Siva Subramanian (6/30/2011 at 7:04 PM)
Excellent article! Most hospitals understand that they are at some financial risk but not every one has a clear picture of how bad it will be once the penalties go into effect. Once they have this picture, they will need to work on improving readmission rates through quality improvement interventions (e.g. Project BOOST, Project RED). The challenge will be to do it in a way that is not only effective but also repeatable, measurable and sustainable over time. This is where IT tools can help. We, at CareinSync (www.careinsync.com), have developed a collaborative care transitions management tool that helps a multidisciplinary team manage patient care transitions in a way that not only improves quality of care and reduces readmissions but also improves efficiency. By incorporating the hospitals chosen QI interventions and monitoring them using collaborative checklists, messaging and alerts, the tool ensures that team is always in sync with the patient discharge plan. A real-time dashboard gives up-to-date and accurate status of the patient discharge plan. Another dashboard provides management and executives with real-time quality and efficiency metrics. For more information please contact me at info@careinsync.com

Su (6/30/2011 at 5:52 PM)
At most hospitals, diabetes and and poor glycemia control contribute to high rates of readmission. Earlier this year, MX.com and Adventist Health System partnered to create the Readmission Reduction through Glycemia Management toolkit for inpatients, specifically designed to help hospital leaders improve readmission rates arising from diabetes-related complications. Diabetes and related complications continue to take their toll. The Lancet just reported an astonishing statistic: Diabetes has tripled in the U.S. and doubled worldwide. (Apologies if this gets posted multiple times. It doesn't seem to take.)