Provider-Based Population Health

Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries, and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.

Causes of Readmissions

The immediate cause of a readmission is usually a rapid deterioration in the patient’s condition, related to the patient’s primary diagnosis and/or comorbidities. But in a broader sense, it can be attributed to systemic failures that often begin in the hospital and continue in the fragmented healthcare settings that patients move through after discharge.

The literature on care transition problems shows there are five main areas that contribute to preventable readmissions:

• Poor preparation for discharge
• Patients’ low health literacy and comprehension
• Failure or inability of patients to see physicians for follow-up after discharge
• Lack of hospital follow-up
• Lack of communication between inpatient and outpatient providers

Readmissions occur, by definition, after a patient has left the hospital. Yet the foundation for post-acute care is laid during the hospital stay—and that preparation is often inadequate.

The Role of Medication Reconciliation

A prime safety issue cited by many experts is missing or inadequate medication reconciliation at the time of discharge. The medications that patients received in the hospital are often discontinued at discharge, while the drugs they were taking before they were admitted may or may not be resumed. Dosages may also change.

The Joint Commission has identified medication reconciliation as a key requirement for ensuring patient safety. The Institute for Healthcare Improvement also cites medication reconciliation as an opportunity to reduce readmissions. This is clearly an area in which improved follow-up and communication between a hospital and a patient’s post-discharge providers could significantly contribute to lower rehospitalization rates.

Improving Patient Health and Safety

By preventing readmissions, healthcare organizations could improve patient health and safety while responding to new government incentives and penalties. A patient-centered, automated approach is the most efficient and cost-effective way to reach out to all discharged patients not just once, but repeatedly over the critical 30- to 60-day period post discharge.  Such a model, judiciously combined with high-touch care management for high-risk patients, is the most efficient and cost-effective way to make sure that all patients who have been discharged are contacted and their healthcare needs are properly addressed.

Written by: Marina Pascali on November 11, 2011.