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12 Ways to Reduce Hospital Readmissions

Cheryl Clark, for HealthLeaders Media, December 27, 2010

12. Listen to the Patient

Involve the emergency room, hospice or home health providers to make sure patients don't come to the emergency room for non-emergent end-of-life care issues.  Providing patients and their family members with informed choices, opportunities for advance directives, and counseling in the emergency room setting may avert painful, unnecessary admissions. Look for this to be a major expansion of palliative care professionals inside the ED.

"There really needs to be a care plan that reflects the patient's wishes," Jencks says. "This is quite different from either a medical power of attorney or what is often called a living will because it lays out the goals of treatment.

"Cure?  Palliation?  Functional independence?  Playing dominoes with friends?  Hospice? This kind of plan has little relevance to persons without substantial chronic conditions, but it is totally relevant to a patient with one or more chronic conditions that have required hospitalization.  With such a plan, one can often avoid readmissions that really do not serve the patient’s needs or values.  What is, after all, worse than a readmission?  Readmission of a patient who does not want to be readmitted," Jencks says.

See Also:
Readmissions Reduction Effort at Kaiser Involves Cameras
Revolving Door Of Readmissions and ED Visits More Extensive and Expensive
What a TV Show Can Teach Us About Readmissions
Facilities Get Creative to Reduce Hospital Readmissions


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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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