What interventions at discharge can reduce hospital readmission?

Effective Interventions to Reduce Hospital Readmissions

Comprehensive transitional care programs that begin during hospitalization and continue after discharge, with a focus on patient empowerment, are the most effective interventions for reducing hospital readmissions. 1

Key Components of Effective Readmission Reduction Interventions

Pre-Discharge Interventions

• Medication Reconciliation

  • Review all new or changed medications with patients and caregivers before discharge 1
  • Ensure electronic linkage of inpatient and outpatient prescription records when possible 1

• Discharge Planning and Communication

  • Implement standardized discharge instructions with structured teaching 2
  • Schedule follow-up appointments prior to discharge with patient agreement on time and place 1
  • Transmit discharge summaries to primary care providers as soon as possible 1
  • Provide diagnosis-specific written instructions to improve understanding, recall, and compliance 2

• Patient Education

  • Educate patients on disease management, medication administration, and when to seek help 1
  • Document patient and family education (lack of documentation associated with 2.3 times higher readmission risk) 3
  • Consider pictograms to represent ideas or concepts for patients with low literacy 2

Post-Discharge Interventions

• Follow-up Contact

  • Implement nurse-led follow-up phone calls within 72 hours of discharge (shown to reduce 7-day readmission rates from 4.73% to 2.91%) 4
  • Schedule earlier appointments (1-2 weeks) for high-risk patients 1
  • Arrange home health visits for high-risk patients 1

• Care Coordination

  • Implement transitional care models that bridge inpatient and outpatient settings 1
  • Use a nurse focused on the discharge process to assist with follow-up appointments, medication reconciliation, and patient education 2

Effectiveness of Different Intervention Types

Timing of Interventions

• Interventions that start during hospital stay and continue after discharge are more effective than those starting after discharge only 5
• Multifaceted transitional care interventions show benefit in reducing readmissions, particularly in the first 12 weeks after discharge 6

Intervention Components

• Patient empowerment-oriented interventions are more effective compared to other types of interventions 5
• More intense interventions reduce the likelihood of readmissions; lower-intensity interventions do not 2

High-Risk Patient Identification

Target interventions toward patients with these risk factors:

• Age 80 years or older (1.8 times higher risk) 3
• Previous admission within 30 days (2.3 times higher risk) 3
• Five or more medical comorbidities (2.6 times higher risk) 3
• History of depression (3.2 times higher risk) 3
• Lower socioeconomic/educational status 1

Program Implementation Considerations

Measurement and Analysis

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

Avoiding Unintended Consequences

• Balance readmission reduction efforts with mortality prevention 1
• Be aware that focusing solely on readmission metrics may inadvertently increase mortality if necessary hospitalizations are avoided 1
• Consider socioeconomic status in readmission measures to avoid creating disincentives for hospitals caring for high-risk populations 1

Evidence of Impact

• The Hospital Readmissions Reduction Program (HRRP) has been associated with decreased readmission rates, with raw all-cause hospital readmissions for target conditions decreasing from 17.9% to 15.8% between 2008 and 2016 2
• Hospitals with superior post-discharge readmission rates show better performance on other quality metrics 2
• Nurse-led discharge follow-up phone call programs have demonstrated a reduction in 7-day readmission rates (2.91% vs. 4.73%) and 30-day readmission rates (11.00% vs. 12.17%) 4
• Combined exercise programs and nurse home visits with telephone follow-up can reduce unplanned readmissions by 3.6 times at 28 days and 2.13 times at 12 weeks 6

Pitfalls to Avoid

• Relying solely on administrative coding changes rather than true quality improvement 2
• Implementing low-intensity interventions that don't address multiple risk factors 2
• Failing to document patient and family education 3
• Starting interventions only after discharge rather than beginning in the hospital 5
• Focusing exclusively on readmission metrics without considering other important outcomes like mortality 1

By implementing comprehensive transitional care programs that span both pre-discharge and post-discharge periods, with particular emphasis on patient empowerment, healthcare systems can effectively reduce hospital readmissions and improve patient outcomes.