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Critical Components of a Robust Readmission Reduction Program

When patients return to the hospital within 30 days for the same condition, it should raise some questions: Were they discharged too early? What was the quality of their follow-up care? Were these patients appropriately educated about the transition out of the hospital?

Hospitals and health systems seek to answer these questions to determine if the readmission was preventable — and for good reason. Hospital readmissions are a frequent occurrence in the United States, costing the healthcare system an estimated $52.4 billion annually.

To provide more context: At least 20% of Medicare patients are readmitted within 30 days, with rehospitalization costs ranging anywhere between $10,900 per person to $16,400 — sometimes more.

With the introduction of the Hospital Readmissions Reduction Program (HRRP) in 2012, Medicare aimed to encourage hospitals to reduce avoidable readmissions through a value-based purchasing program penalizing hospitals with higher-than-expected readmission rates by reducing Medicare payments.

Medicare’s definition of readmission is any unplanned admission to any hospital within 30 days after discharge, regardless of the reason for the new admission. Under this definition of readmission, the only exception is planned admissions. Even admissions unrelated to the original condition or those that occur at different hospitals count when the Centers for Medicare & Medicaid Services (CMS) computes readmission rates.

Goals of HRRP including encouraging hospitals and health systems to improve communication and care coordination to better engage patients and caregivers in discharge plans, but HRRP does not specify guidelines on how to accomplish these objectives.

This means that each hospital must evaluate its policies and determine how and where to adjust to address issues surrounding readmissions and then craft a readmissions reduction program to achieve these improvements. But where to start?

Creating a Program to Reduce Your Readmission Rate

Designing a readmission reduction program allows hospitals to improve the quality of the care they deliver while avoiding costly penalties for noncompliance with HRRP guidelines, thereby lowering their overall costs. It’s also a chance to maintain — or reclaim — their quality-of-care reputation ratings.

The findings in a recent study published in JAMA Network Open suggest that communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction, and thus are important for facilitating this transition of care. Research shows that when patients are engaged in their healthcare, it can lead to measurable improvements in safety and quality. In short, better communication and engagement are wins for providers and patients.

Now let's explore three crucial communication and engagement components of any effective readmission reduction program.

Medication Reconciliation

Proper medication reconciliation, including medication reconciliation post-discharge (MRP), helps avoid preventable medical errors by maintaining accurate medication records. CMS defines the medication reconciliation process as “identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider.”

Though it sounds straightforward, if a patient's medication history is captured inaccurately during admission just once, the misinformation can follow a patient throughout and following their treatment, potentially leading to harmful medication errors and increased costs for patients and organizations.

As a best practice, an external list of medications should be obtained from a patient, hospital, or another provider during every transition of care to avoid information gaps. A study cited in Hospital Pharmacy found that a pharmacist-facilitated medication reconciliation program and patient education significantly decreased 30-day readmission rates in patients with chronic medical conditions. The intervention reduced readmissions by 27%.

Proper medication reconciliation can also help decrease costly readmissions by reducing patient and caregiver burden by reducing medication errors and adverse drug events (ADEs). A readmission reduction program that includes better safeguards to combat these issues is key to better medication management practices.

Structured Discharge Communications

Smooth discharge planning happens when a patient is effectively and safely transitioned from the hospital to the home or other post-discharge setting. Unfortunately, a variety of barriers are associated with successful post-discharge patient transition. A few of the most common are lack of hospital resources, limited patient readiness, and unidentified social determinants of health (SDoH).

So, what is the best place to start with improving your discharge process? Begin by teaching hospital staff and clinicians how to develop proper discharge plans that take these transition barriers into account and outline clear instructions for the patient to follow post-discharge. The Agency for Healthcare Research and Quality (AHRQ) has developed the IDEAL Discharge Planning Tool to help hospitals successfully transfer information from clinicians to the patient and family to reduce adverse events and prevent readmissions. The acronym outlines the following specific actions to take:

  • Include the patient and family as full partners in the discharge planning process.
  • Discuss with the patient and family five key areas to prevent problems at home:
    • describe what life at home will be like;
    • review medications;
    • highlight warning signs and problems;
    • explain test results, and
    • make follow-up appointments.
  • Educate the patient and family in plain language about the patient’s condition, the discharge process, and any next steps at every opportunity throughout the hospital stay.
  • Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use the teach-back method.
  • Listen to and honor the patient and family’s goals, preferences, observations, and concerns.

Tailored Patient Education Efforts

A readmission reduction program should aim for better patient engagement rates. One strategy to accomplish this goal is to tailor and improve patient education. To achieve better patient outcomes and reduced readmissions, patients and their families must understand the patient’s diagnosis, follow-up needs, and whom to contact with questions or if problems develop following discharge. A patient-centric approach to discharge education can lead to better adherence and overall continuity of care. For example, research has shown that a personalized discharge plan, unlike a routine discharge plan, can effectively reduce readmissions. A written transition plan that can be shared should include details on medication management.

Get Expert Help With Your Readmissions Reduction Program

These key components of a successful readmission reduction program can have a significant impact on quality of care, which can lead to reduced rehospitalizations over the long term. By combining these efforts with Cureatr’s robust medication management system that provides a complete picture of a patient’s medication history for medication reconciliation, hospitals and health systems can provide seamless — and safe — discharge planning.

Cureatr helps hospitals and health systems avoid poor medication reconciliation processes that can lead to ADEs and suboptimal outcomes which contribute to readmissions and significant expenses. Learn about common medication reconciliation errors and ways to improve your approach to med rec by downloading a copy of “Medication Reconciliation: The Biggest Patient Safety Issue Facing Clinicians Today.” 

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