Hospitals ought to invest in processes that keep discharged patients from returning, and should do so for two main reasons, a new report argues: (1) readmissions are costly and are increasingly a concern for Medicare, Medicaid, and private payers, and (2) steps to reduce readmissions will prepare hospitals for future efforts to promote continuity of care.

The report, published by the CSC Global Institute for Emerging Healthcare Practices, outlines evidence-based approaches to reduce hospital readmissions. The authors define readmission as a return hospitalization to an acute care hospital that follows a prior acute care admission within 30 days, which is the standard used by the Centers for Medicare and Medicaid Services. (CMS).

“There is no magic bullet,” the authors caution.  “The combination of comprehensive discharge planning with post-discharge support reliably reduces readmissions, at least for one high-risk patient population: older patients with heart failure.” Both discharge planning and post-discharge support, as laid out in this paper, revolve around effective communication among hospitals, patients, and physicians providing post-hospitalization care. Electronic health record (EHR) systems and other health information technology in general should facilitate post-discharge care coordination.

Based on a review of research on practices to reduce hospital readmissions, the report outlines six essential, evidence-based steps:

Discharge Planning Steps:

  1. Assess transition risk
  2. Prepare the patient
  3. Develop post-discharge plan of care

Post-Discharge Support Steps:

  1. Prepare the next provider of care
  2. Ensure post-discharge follow-up
  3. Ensure post-discharge support

In addition to effective communication, the steps include suggestions for how hospitals can ensure patients get follow-up care. Half of Medicare patients with a medical condition readmitted within 30 days did not have a physician visit since leaving the hospital, according to one analysis the paper cites. The CSC experts counsel hospitals to become directly involved in follow-up care – by identifying and contacting the patient’s next care provider and pharmacy, and by scheduling follow-up visits for patients. The report does not attempt to quantify how costly it would be for hospitals to put the recommended procedures in place, many of which would require staff resources: nurses or doctors who perform post-discharge home visits, and hospital staff to coordinate with physicians and to serve as transition coaches.

Although the paper cites research showing the significant costs associated with readmissions, it is unclear how much net savings hospitals might recoup after investing in anti-readmission procedures.  Traditional fee-for-service payment rewards hospitals for readmissions and creates strong financial disincentives for improvement.  This, of course, is the primary reason Medicare and state Medicaid programs are measuring preventable readmissions and changing inpatient payment methods to penalize hospitals financially for excessive readmission rates.

Nevertheless, the authors view reducing readmission as a stepping stone to larger attempts to promote continuity of care, arguing that more insurers and institutions will begin paying attention to transitions in care. Hospitals, they say, “are on point already and have the burden of taking the lead,” and “organizations that build capacity for collaborative continuity of care will be better able to tackle the challenges of the future.”