When a patient is discharged from the hospital, it is under the assumption their condition has improved enough that they can safely return home. According to the Agency for Healthcare Research and Quality (AHRQ), more than 70% of patients who have been hospitalized are able to return home without being closely supervised. Another 10% of patients are discharged home with healthcare supervision.
Unfortunately, too many of these discharged patients end up being readmitted to the hospital, often within the first month following their discharge. In 2018, the AHRQ reported that there were 3.8 million 30-day all-cause adult hospital readmissions, with a 14% readmission rate across all payers. Medicare beneficiaries had the highest readmission rate (about 17%), while self-pay or no-charge patients had the lowest rate at about 12%.
But, what does this tell us about the factors that can contribute to higher hospital readmission rates? Before we dive into this important topic, let’s examine how these rates are calculated so we can better understand how to interpret the data.
How CMS Readmission Rates Are Calculated
The Centers for Medicare & Medicaid Services (CMS) defines readmission as “an admission to a hospital within 30 days of a discharge from the same or another hospital.”
CMS uses several steps to calculate a hospital’s 30-day risk-standardized readmission rate (RSSR). The calculation can be broken down into the following formula:
(Predicted 30-day readmission/Expected readmission) * U.S. national readmission rate = RSRR
According to CMS, planned readmissions are excluded from RSRR measures. Planned readmission is non-acute readmission for a scheduled procedure. Certain types of care, such as obstetrical delivery or transplant surgery, are always considered planned.
Hospital Readmission Facts: How Rates Have Changed Over the Years
Hospitals once lacked a financial incentive to reduce their readmissions, but that all changed once the Hospital Readmissions Reductions Program (HRRP) was introduced in 2012. This value-based purchasing program was designed to encourage hospitals to avoid potentially preventable readmissions through improved communication and care coordination. CMS calculates a payment reduction for each hospital during a rolling period based on its readmission performance.
The Medicare Payment Advisory Commission (MedPAC) found that, with the implementation of HRRP, hospital readmission rates fell, and raw readmission rates declined for all-cause, unplanned, and potentially preventable readmissions. Those with the lowest performance prior to HRRP had the most significant improvement. MedPAC’s analysis also showed that in 2016, Medicare spent about $2 billion less on readmissions because of the program.
Although, there is still a lot of work to be done to reduce readmissions. Nearly 3,000 hospitals have been penalized at least once since HRRP was implemented. That’s 93% of the general acute hospitals subject to the program and 55% of all U.S. hospitals. Not only that, but nearly 1,300 hospitals have been penalized yearly for their high readmission rates since the program began.
In light of the COVID-19 pandemic, CMS made payment adjustments that resulted in the lowest penalties hospitals have received since HRRP's implementation. The agency excluded claims data from the first half of 2020 and suppressed pneumonia readmissions. With these adjustments, about 18% of hospitals did not receive a readmissions penalty for fiscal year (FY) 2022. For FY 2023, about one-quarter of hospitals subject to HRRP will not receive CMS readmission penalties.
Now let's explore the underlying causes of hospital readmissions to understand more about this complex problem.
What Contributes to High Hospital Readmission Rates
While financial penalties are one way to encourage hospitals to reduce their readmission rates, it’s equally important to look at the factors that cause them in the first place. As stated in the CMS readmission definition, when patients return to the hospital after discharge, it can indicate that their care wasn’t properly organized. One observational study found that approximately one-third of readmissions are potentially preventable.
Here are some hospital readmission facts about the factors most strongly associated with preventability:
- Emergency department decision-making regarding the readmission
- Failure to relay important information to healthcare professionals
- Premature discharge
- Lack of discussion about care goals among patients with serious illnesses
Other factors that were independently associated with potentially preventable readmissions were the inability to keep appointments after discharge and the lack of awareness of whom to contact following discharge. Potential underlying factors that had the largest absolute differences in prevalence between preventable and non-preventable readmissions include:
- inadequate treatment of symptoms other than pain;
- inadequate monitoring for adverse medication effects or medication nonadherence; and
- patient need for additional or different home services than those included in discharge plans.
The data here points to ways that healthcare systems and hospitals can tackle the problem of readmission.
Interventions to Reduce Unnecessary Hospital Readmissions
Although HRRP has contributed to lower hospital readmission rates, the program only focuses on six conditions and procedures: acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty and/or total knee arthroplasty. Reducing unnecessary hospital readmissions on a broader level requires multiple interventions, including some that are non-specific to a patient's condition or procedure.
One of the factors contributing to hospital readmissions is a lack of care coordination, whether that’s due to providers not communicating with each other or a failure to provide patients with the right services post-discharge. Interventions to improve care coordination can include the following:
- Medication reconciliation upon admission and following discharge (i.e., medication reconciliation post-discharge, or MRP) by a clinical pharmacist
- Linking community resources or home health services for patients with limited resources
- Disease-specific evidence-based teaching material that is introduced to the patient within 24 hours of admission
- Follow-up appointments made within 72 hours of discharge, allowing the patient to get settled at home but not allowing too much time to pass before they receive further care support
- Utilizing the teach-back method during patient education interventions
Research has found that hospitals that use more recommended care transition processes had lower risk-standardized hospital readmission rates. Through a 10-site observational study, researchers developed a list of 20 care transition processes that had been shown to reduce readmissions either independently or when combined with other processes. The study concluded that performing all the recommended care transitions consistently and for all patients — not just those at high risk of hospital readmission — could have the potential to further reduce early readmissions.
Furthering Your Understanding of How To Reduce Hospital Readmission Rates
Excessive readmissions are detrimental not only to hospital revenue but to patients' health outcomes as well. High readmission rates can also harm a hospital's overall star rating. Addressing factors contributing to readmissions, such as medication-related issues, can keep patients out of the hospital and in their own homes.
When patients do not adhere to their medication regimen, it increases the likelihood of readmission. Learn practical strategies to drive meaningful improvement with this complex issue by downloading the detailed eBook, "Medication Adherence: A Comprehensive Guide for Providers," produced by the medication experts at Cureatr.