What is Hospital Readmission - Health Systems Institute

Hospital Readmissions
Pramit Sengupta
Health System Institute
Georgia Institute of Technology
What is Hospital Readmission
A readmission is defined as a hospitalization
that occurs shortly after a discharge; which
is most often measured as within 30 days
but it could be shorter or longer. Such
readmissions are often but not always
related to a problem inadequately resolved
in the prior hospitalization.
Hospital Readmission
They also can be caused by deterioration
in a patient’s health after
discharge due to inadequate
management of their condition,
misunderstanding of how to manage it, or lack
of access to appropriate services or
Prevalence of Readmission
For most patients who leave the hospital, the
last thing they want is to return anytime soon.
Yet, many Medicare patients discharged
from an inpatient stay find themselves back in
the hospital within 30 days.
Major Factor for Readmission
Multiple factors contribute to avoidable
hospital readmissions: they may result from
poor quality care or from poor
transitions between different providers and
care settings.
Cost of Readmission
Hospital readmissions are massively expensive.
A recent study of Medicare patients found that
one in five admissions results in a
bounce back within 30 days of discharge,
costing the federal government an
estimated $17.4 billion per year.
Top Diseases for Initial Hospitalization
Diabetes Mellitus
Drug Abuse
Heart Failure
Urinary Tract Disorder
Measures to Reduce Hospital
A review of studies published from 1998 to 2008
revealed that a variety of quality improvement
and process redesign approaches have lowered
readmission rates.
These includes: close coordination of care in the
post-acute period, early post-discharge follow-up
care, enhanced patient education and selfmanagement training, and extending the
resources and clinical expertise available to
patients over time.
Identify High Risk Patients
The hospitals identify and target patients at the
highest risk for readmissions, particularly heart
failure patients, the very elderly, patients with
complex medical and social needs, and those
without the financial resources to obtain
post-hospital care.
Care Management
Begin care management and discharge planning early, target high-risk
patients, and ensure frequent communication across the care team.
Telephone calls, Tele monitoring
Maintain a lifeline with high-risk patients after discharge through
telephone calls, tele monitoring, or other practices.
Educate the patient
Educate the patient about his or her diagnosis throughout the
hospital stay
Post-discharge services
Organize post-discharge services
Healthcare Information Technology
Use of health information technology (e.g., electronic health records,
patient registries, and risk stratification software) to improve quality and
integrate care across settings.
Hospital Acquired Infections
Use of Technology
Twice daily, Raymond Racette from Phillipston, Mass. downloads
information about the fluid levels in his heart, and off it goes to the
Community Health Providers
Align hospitals’ efforts with those of community providers to provide a range
of care. While this may be best achieved in integrated systems, such
cooperation can be facilitated through collaborative relationships among
hospital and community providers.
Discharge Instructions
Easy to understand discharge instruction
Medical Reconciliation
Medication reconciliation is the
process of comparing a patient's
medication orders to all of the
medications that the patient has
been taking.

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