What are the best practices for reducing hospital readmissions?

Hospital Readmission Reduction Best Practices

The most effective strategy to prevent hospital readmissions is implementing comprehensive transitional care programs that begin during hospitalization and continue after discharge, with a particular focus on patient empowerment and structured discharge planning. 1

Key Components of Effective Readmission Reduction Programs

Structured Discharge Planning

• Medication Reconciliation:

  • Cross-check home and hospital medications to ensure no chronic medications are stopped
  • Review new or changed medications with patients and caregivers before discharge 2
  • Ensure electronic linkage of inpatient and outpatient prescription records when possible 1

• Discharge Communication:

  • Transmit discharge summaries to primary care providers as soon as possible after discharge
  • Include information on medication changes, pending tests, and follow-up needs 2
  • Schedule follow-up appointments prior to discharge with patient agreement on time and place 2

• Patient Education Before Discharge:

  • Identify healthcare providers who will provide care after discharge
  • Educate on disease management, medication administration, and when to seek help
  • Provide information on healthy food choices and refer to specialists as needed
  • Ensure proper education on sick-day management 2
  • Provide appropriate durable medical equipment, medications, and supplies at discharge 2

Post-Discharge Interventions

• Timely Follow-up:

  • For patients with medication changes or suboptimal glucose management, schedule earlier appointments (1-2 weeks) 2
  • Implement home health visits for high-risk patients 2

• Care Coordination:

  • Establish partnerships between hospitals, community physicians, and local hospitals for managing high-risk patients 1
  • Implement transitional care models that bridge inpatient and outpatient settings 2
  • Consider collaborative patient-centered medical homes for patients with complex conditions 2

Risk Stratification and Targeted Interventions

• Identify High-Risk Patients:

  • Male sex, longer prior hospitalization, multiple previous hospitalizations, and comorbidities are risk factors 2
  • Lower socioeconomic/educational status increases readmission risk 2
  • Age is an important risk factor, particularly for older adults 2

• Disease-Specific Approaches:

  • For diabetes: Target ketosis-prone patients with type 1 diabetes 2
  • For diabetes: Consider insulin treatment for patients with admission A1C >9% 2
  • For heart failure and AMI: Implement quality improvement teams specifically focused on these conditions 3

Quality Improvement Framework

• Measurement and Analysis:

  • Track readmission rates and analyze patterns to identify improvement areas 1
  • Conduct root cause analyses of readmissions 1
  • Consider composite measures that include readmissions, mortality, observation stays, and emergency department visits 2

• Program Adjustments:

  • Modify protocols based on findings to continuously improve care quality 1
  • Balance readmission reduction efforts with mortality prevention 2

Common Pitfalls and Considerations

• Avoiding Unintended Consequences:

  • Focusing solely on readmission metrics may inadvertently increase mortality if necessary hospitalizations are avoided 2
  • Inadequate risk adjustment can mask socioeconomic disparities 2

• Equity Considerations:

  • Adjust for socioeconomic status in readmission measures to avoid creating disincentives for hospitals caring for high-risk populations 2
  • Provide additional resources to facilities serving disadvantaged populations 1

• Implementation Challenges:

  • Many hospitals have written objectives to reduce readmissions but vary widely in implementing recommended practices 3
  • Patient empowerment interventions are more effective but require training caregivers to increase patients' capacity for self-care 4

By implementing these evidence-based strategies with particular attention to transitional care that begins during hospitalization and continues after discharge, healthcare systems can effectively reduce hospital readmissions while improving patient outcomes and satisfaction.