For Hospital Readmissions, Hindsight is Not 20/20
KEY WORDS: hospital; readmissions; rehospitalizations; communication;
intervention.
J Gen Intern Med
For Hospital Readmissions, Hindsight is Not 20/20
Rosa R. Baier 1 2
Amal N. Trivedi 0 1
0 Providence VA Medical Center , Providence, RI , USA
1 Department of Health Services, Policy & Practice, Brown University School of Public Health , Providence, RI , USA
2 Center for Long-Term Care Quality & Innovation, Brown University School of Public Health , Providence, RI , USA
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A ment is a continuous process that requires gathering
s Deming and others have described, quality
improveinformation to define a problem and then testing and studying
interventions that address its root causes. But how can
providers intervene when they disagree about the contributing
factors—or even the extent to which poor outcomes reflect
suboptimal quality of care?
Transitional care is one area where there is broad debate
about how to characterize problems and intervene. Because
returning to the hospital following discharge is common,
costly, and burdensome to patients and their caregivers,
reducing readmission rates has emerged as an important quality
goal. Many believe that some readmissions, perhaps 25% or
more,1 could be prevented with better care: for example, if
inpatient-outpatient communication occurred more seamlessly
and if patients understood and acted on recommended
followup. As a result, Medicare and other insurers are using
readmission as a marker of poor quality care and financially
penalizing hospitals (and soon nursing homes) for Bhigher
than expected^ 30-day readmission rates. This makes it
increasingly pressing to identify effective strategies to prevent
readmissions.
Recent evidence has documented that national readmission
rates are, in fact, declining,2 though the precise mechanisms
remain unclear. Although there are many well-known
readmissions reduction programs targeting different factors,
systematic reviews demonstrate programs’ variable success
and highlight the need for additional research to characterize
the components of successful interventions.3, 4
I m p l e m e n t i n g e ff e c t i v e i n t e r v e n t i o n s t o r e d u c e
readmissions is deceptively difficult. Consider, for instance,
an action as seemingly simple as notifying primary care
physicians (PCPs) that their patient was hospitalized. For these
notifications to be effective, hospital staff must identify the
correct PCP or practice location, ensure communications
contain complete and accurate information and are successfully
transmitted, and reach the right person—whether that person is
the PCP, a nurse care manager, or someone else in the practice.
The primary care practice must then act on the notification of
the hospital visit, perhaps by providing pertinent information
during the inpatient stay or by following up with the patient
post-discharge.
Of course, preventing readmissions is far more complex
than solely notifying the PCP. Numerous barriers affect
patients’ post-hospital care transitions and contribute to
readmissions—far too many to detail. These include failure
to prospectively identify and coordinate care for patients at
highest risk for readmissions. They also include
socioeconomic factors and lack of adequate access to care that affect
patients’ ability to obtain needed medications or services
(medical or otherwise) and to keep follow-up appointments.
Any single barrier can result from multiple root causes, each of
which could be targeted for intervention. In light of this
complexity, how can we implement systems change that
improves communication and coordination for all patients, at all
points in the care continuum? And how can we target or tailor
assistance to those at highest risk?
Agreeing where to start is key. In this issue of the Journal of
General Internal Medicine, Herzig et al. present results of a
study that asked PCPs, admitting physicians, and discharging
physicians to identify factors contributing to specific patients’
readmissions and strategies to prevent readmissions.5 The
resulting data highlight numerous opportunities for
intervention, such as improved inpatient-outpatient communication
and information transfer during and after the hospital stay.
This could include not only notification of PCPs at hospital
admission and provision of timely discharge summaries to
PCPs, but also PCPs’ reciprocal responsibility to provide
inpatient physicians with information that informs inpatient
care and discharge planning. Communication could occur via
a phone call or conversation, though physicians’ busy
schedules may not always make that possible. Therefore, sharing of
clinical records, ideally in real time, is essential. Without
sharing of outpatient medical records, inpatient physicians
may plan discharge without important details of a patient’s
clinical history, social context, and ability to self-manage care.
Without timely transfer of discharge summaries, PCPs may be
faced with caring for a recently dischar (...truncated)