For Hospital Readmissions, Hindsight is Not 20/20

Journal of General Internal Medicine, Aug 2016

Rosa R. Baier MPH, Amal N. Trivedi MD, MPH

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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 - 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)


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Rosa R. Baier MPH, Amal N. Trivedi MD, MPH. For Hospital Readmissions, Hindsight is Not 20/20, Journal of General Internal Medicine, 2016, pp. 1270-1271, Volume 31, Issue 11, DOI: 10.1007/s11606-016-3821-0