Boosting collaboration between hospitals and community-based caregivers is a daunting but surmountable hurdle, West says.
"The starting point for any collaboration is identifying the unmet need of the patient or gap in service delivery. Both partners must be able to articulate how the collaboration enhances patient care and fills the service gap," he said. "Finally, any collaboration also requires that all partners understand each other's financial incentives and costs associated with new programming."
The research Goldman and Linden conducted identified elderly, seriously ill patients as not only prone to readmission, but also difficult to help with intervention efforts. "I wish there was a simple answer, but there is no simple answer," Linden says. "When you have congestive heart failure, you're at the end of the road."
Turner said part of solving the readmission puzzle has to be a change in mindset away from always striving for curative care and toward acceptance of a more comprehensive approach to end-of-life care.
"For many individuals with serious illness, a primary goal of care is avoiding hospitalization, and a primary driver for hospitalization is an exacerbation of pain and symptoms," he said. "Palliative care teams can often obviate readmission through expert pain and symptom management, and effective communication on prognosis and goals of care. Moreover, the interdisciplinary composition of a palliative care team helps identify social determinants that may contribute to hospitalization."
Christopher Cheney is the senior clinical care editor at HealthLeaders.