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Readmission Definition: What to Know About This Important Hospital Concept

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Improve Medication Management and Health Outcomes With Clinical Pharmacist Support

Readmissions are a major concern for the healthcare industry, which hospitals have been contending with for years. According to a report by the Agency for Healthcare Research and Quality (AHRQ), there were 3.8 million 30-day all-cause adult hospital readmissions in 2018. Hospitals experienced a 14% readmission rate, with each readmission costing an average of more than $15,000. 

Numerous studies have examined the factors contributing to such high rates. Research has shown that approximately 20% of hospital readmissions are medication related, with nearly 70% of those readmissions should’ve been potentially prevented. Studies also reveal that patients with low to intermediate medication adherence had higher readmission rates than patients with high adherence. 

Hospital readmissions don’t just affect patients. They also affect payers and the hospitals themselves and can lead to severe readmission penalties and harm to quality ratings if they are not addressed. To better understand the impact of hospital readmissions and how they can be prevented, it is important to understand what readmission is and why it happens.

Understanding the Readmission Definition 

The Centers for Medicare and Medicaid Services (CMS) provides a succinct yet helpful readmission definition. CMS states that readmission is a “situation where you (a patient) were discharged from the hospital and wind up going back in for the same or related care within 30, 60, or 90 days.” This includes readmissions to any hospital, not just where the patient was initially hospitalized. 

Medicare also provides an “all-cause” readmission definition: Any hospital stay within 30 days of discharge is considered a readmission, no matter the reason. 

Readmissions are often used to measure a hospital’s quality of care. Too many readmissions can mean that post-discharge care was not properly organized and completed or the patient did not receive proper treatment while hospitalized. Patients may be discharged too early or transferred to a setting that does not support their recovery. This can have an adverse effect on a patient’s health outcome. Readmissions increase the risk of patient stress and mortality. And while hospitals can only control some of the factors that lead to readmission, they are still held accountable. 

Although CMS’s readmission definition does not distinguish between planned and preventable readmissions, the agency added an exception for planned hospitalizations within a 30-day period in 2014. 

How Do Hospital Readmissions Affect Payments?

The Patient Protection and Affordable Care Act (ACA) established the Hospital Readmission Reductions Program (HRRP), a Medicare value-based purchasing program, in 2012. The HRRP encouraged hospitals to engage with patients and their caregivers in discharge planning to reduce avoidable readmissions. CMS estimated that Medicare would save more than $500 million due to HRRP. 

Under the program, hospitals are financially penalized if they have higher than expected 30-day readmission rates for six targeted conditions and procedures: 

  • Acute myocardial infarction 
  • Chronic obstructive pulmonary disease 
  • Heart failure 
  • Pneumonia
  • Coronary artery bypass graft surgery
  • Elective primary total hip arthroplasty and/or total knee arthroplasty 

Payment reductions apply to all Medicare fee-for-service base operating diagnosis-related group (DRG) payments during the fiscal year, which runs from October 1 to September 30. Reductions are capped at 3% or a payment adjustment factor of 0.97. 

Since the start of the program, nearly 3,000 hospitals — 93% of eligible hospitals and 55% of all hospitals — have been penalized at least once, the Kaiser Family Foundation reports. Of those, close to 1,300 were punished in all ten years. As of 2021, only 219 eligible hospitals have avoided payment reductions. Hospitals with specialized functions, such as long-term or psychiatric care, are exempt from readmission penalties. 

Readmissions can cause financial harm to hospitals in another way: by negatively affecting quality ratings. As Founder of Innovation Horizons, LLC, Gregory Downing, DO, Ph.D., states, "If a hospital experiences a significant increase in readmissions year over year, and generally the star ratings look at three-year time blocks, then CMS could decrease a percentage of its payment to the hospital for subsequent years. … One percent or two percent decline because of readmissions can be a substantial factor in a hospital's budget." 

Strategies for Reducing Hospital Readmissions

Readmissions can be extremely costly for patients, providers, and payers. The good news is research has shown that more than a quarter of readmissions can be prevented with proper communication between providers and patients. And that's not the only tactic for reducing hospital readmissions. 

Engage Patients to Lower Readmission Rates

Prioritizing patient engagement is effective in reducing hospital readmissions. Patients often receive conflicting or unclear information at discharge or may not be involved in discharge planning. Without a clear understanding of their condition, the importance of taking their medication, and instructions for follow-up care, patients have an elevated risk of readmission. Patients who reported on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys that they were not engaged in their care were 34% more likely to be admitted to the hospital within 30 days of discharge, according to a study published in Patient Experience

Hospitals can also reduce the risk of rehospitalizations by utilizing discharge planning toolkits, such as Project BOOST and IDEAL Discharge Planning. These toolkits provide checklists for the patient’s care team to complete and include resources for patients to learn how to better care for themselves at home. 

Medication Adherence and Care Coordination Lower Readmission Risk 

Since almost one-fifth of readmissions are medication related, one way to reduce them is to improve medication adherence. Patients don’t take their medications for several reasons, including cost, fear of side effects, mistrust, misunderstanding, or juggling too many medications.

To mitigate the risk of medication non-adherence, healthcare organizations should focus on reconciling a patient’s medications following discharge (i.e., medication reconciliation post-discharge or MRP). Inaccurate or incomplete medication lists can cause adverse drug events (ADEs) that lead to readmissions. This is especially true when patients receive care across a number of different settings, which can increase the likelihood that patients will only remember some of the different medications they have been prescribed. 

If healthcare providers do not have a complete list of a patient’s medications, they can potentially prescribe one that negatively interacts with a drug the patient is already taking. This points to the importance of improved care coordination. As Downing notes, "We have worked with a hospital system that went from 4 stars to 5 this past year. One of the major contributing factors was a care coordination program that reduced readmissions with the help of improved medication management."

Clinical pharmacist involvement can help further reduce the risk of medication non-adherence. When clinical pharmacists are included on a hospitalized patient's care team, they can review medications and adjust dosages accordingly.  This optimization of a medication regimen can help prevent ADEs that may contribute to rehospitalization.

Improve Medication Adherence to Assist in Reducing Hospital Readmissions

Healthcare organizations looking to reduce the risk of rehospitalizations should understand how CMS views readmissions, from its readmission definition to readmission penalties, to how readmissions are weighted for quality ratings. Gaining a better understanding of these areas can help hospitals identify where to target improvement efforts, regardless of whether a hospital participates in HRRP. Understanding what factors lead to readmission can help hospitals develop strategies to better prepare patients for discharge and stay out of the hospital. 

One such strategy should be emphasizing the importance of taking medication as prescribed. As we discussed, when patients do not adhere to their medication regimen, it increases the likelihood of readmission. Learn more practical strategies to achieve meaningful improvement in the complex issue of medication adherence by reading "Medication Adherence: A Comprehensive Guide for Providers."

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