Preventable Readmissions/Care Transition

A now famous 2009 study published in the New England Journal of Medicine demonstrated that almost one-fifth (19.6%) of Medicare patients were readmitted to the hospital within 30 days of discharge and 34% were readmitted within 90 days. This research estimated that only 10% of these readmissions were planned and that the annual cost to Medicare alone of unplanned hospital readmissions exceeds $17 billion. Performance with readmissions varies.

Medicare 30-day re-hospitalization rate varies 13-24% across states and varies even more significantly within states. Hospitals are making progress reducing avoidable readmissions by employing several effective strategies. While readmissions are the result of a variety of factors, the lack of care coordination and effective transitions of care are important contributors. Addressing complex issues across care settings is difficult and requires new tools, communication channels and care processes.

Several care models and care systems have been created to address the needs of patients in a complex system. Many of these approaches also have research support and/or significant experience with multiple hospitals to warrant consideration. This change package does not endorse any particular model or care system. Rather, common approaches and practices are highlighted. Hospitals should review the models listed in the resources section and determine which approach is more effective for their structure, patient population, and most importantly, the leading causes of readmissions for their patients.

In summary, avoidable re-hospitalizations are: common, costly, variable across and within states and can be reduced with effective care coordination and transitions of care.

Meetings

July 27, 2012 

July 19, 2013 Reduce Readmissions Workshop

Resources

Reducing Hospital Readmissions: LRGH & ServiceLink

Other Activities