How to Reduce Hospital Readmissions

The work of a hospital administrator comes with a laundry list of challenges. This time, we’re not talking about staffing challenges. We’re going to hit the painful point of hospital readmissions. Ouch.

The average cost of a 30-day “all-cause” hospital readmission is over $16,000. When we account for an estimate of 3.8 million annual readmissions, we end up talking about billions of dollars.

What are hospital readmissions?

A hospital readmission occurs when a patient who has been discharged from the hospital is readmitted within 30 days. Readmissions within 30 days of discharge often point to a substandard level of care—except in the case of some planned readmissions.

What’s the difference between planned and unplanned readmissions?

Planned readmissions are exactly what they sound like: part of an ongoing care plan that includes strategic follow-up procedures or interventions. They often reflect care continuity.

How the CMS defines and measures hospital readmissions

The Centers for Medicare & Medicaid Services (CMS) enforces the Hospital Readmissions Reduction Program (HRRP). The HRRP intends to reduce hospital readmissions by leveraging financial incentives to improve care coordination.

The CMS measures a hospital’s readmission performance for the HRRP for the following 6 conditions and procedures:

Acute myocardial infarction (AMI)
Chronic obstructive pulmonary disease (COPD)
Heart failure (HF)
Pneumonia
Coronary artery bypass graft (CABG) surgery
Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)

"Excess readmissions are measured by a ratio, calculated by dividing a hospital's predicted rate of readmissions for heart attack (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), hip/knee replacement (THA/TKA), and coronary artery bypass graft surgery (CABG) by the expected rate of readmissions, based on an average hospital with similar patients." -Centers for Medicare & Medicaid Services

Note: The CMS measures readmissions to any acute care hospital, not solely readmissions back to the initial hospital.

Why are readmissions so important to hospitals?

Aside from the obvious financial incentives from the CMS and the HRRP, hospital readmissions are—and should also be—important to hospitals because they:

Strain hospital resources (beds, staffing, supplies)
Divert resources from other patients who need care
Highlight inefficiencies in discharge planning and patient education
Increase emotional toll, stress, and physical complications on the patient and their families
Erode patient confidence in healthcare
Increase out-of-pocket expenses for patients (copayments, deductibles, missed work, etc.)

What causes hospital readmissions?

Hospital readmissions can occur due to poor care coordination, medication mismanagement, and in-hospital complications, as well as patient-related issues like premature discharge, lack of follow-up care, and social determinants of health.

The article, “Reducing Hospital Readmissions,” published in the National Library of Medicine, cites multiple studies that measured preventable hospital readmissions. These studies found that the percentage of avoidable readmissions ranged from 5% up to a surprising 79%.

This range implies multiple factors that contribute to hospital readmissions, including:

Poor handoffs between healthcare providers (incomplete or erroneous information)
Medication mismanagement (new medicines, new dosages, adverse reactions, polypharmacy)
In-hospital complications (pressure sores, ulcers, falls, etc.)
Patient medication errors (duplication, improper dosing, frequency)
Premature discharges (including leaving against medical advice)
Insufficient or total lack of follow-up care (clinical appointment, medication management, physical therapy, home health, etc.)
Poor coordination and communication between providers
Lack of effective patient education
Social determinants of health (transportation issues, food security, housing stability, support)

How to reduce hospital readmission rates

Here, we define 10 steps to create a robust strategy to reduce hospital readmissions and improve patient satisfaction.

1. Understand the Hospital Readmission Reduction Program

The HRRP is your quality benchmark. The first step to reducing readmissions is understanding the program and the financial implications of noncompliance.

Bottom line, “financial implications” means that the CMS actually reduces payments to hospitals with excess readmissions.

How much are hospital readmission penalties?

The payment reduction is a percentage calculated based on a hospital’s performance.
It is a weighted average across the HRRP performance period.
The payment reduction is capped at 3%.
Hospitals have 30 days from the date they receive their HRRP data to submit questions and requests for corrections.

Note: Acute hospitals in Maryland are not subject to the HRRP because the state has a separate agreement with the CMS.

2. Balance nurse-to-patient ratios

Does nurse staffing affect hospital readmission rates? Yes, it can.

A balanced nurse-to-patient ratio, regardless of census fluctuations, is crucial for preventing hospital readmissions because it affects patient care quality and outcomes.

Adequate staffing levels allow nurses to provide:

Personalized attention
Timely interventions
Thorough patient education
Effective shift handoffs
Complete discharge planning

These nursing services are essential for preventing complications, ensuring medication adherence, and facilitating care coordination among providers.

3. Identify high-risk patients

Recognizing characteristics and circumstances that predispose patients to readmission is crucial.

Facilities can use validated risk assessment tools or predictive models to stratify patients by readmission risk. This approach also helps consider clinical criteria and indicators associated with increased risk of readmission, such as:

High-risk medication use
Chronic conditions
Recent hospitalizations or emergency department visits
Complex care needs
Low health literacy
Cognitive impairment
Social determinants of health (SDOH)

4. Reevaluate point of care charting

Is your facility already using point-of-care charting? If not, it may be time to make a change.

Point-of-care charting is the practice of documenting observations, assessments, and provider actions in the medical chart at the patient’s bedside, aka, at the point of care.

This practice reinforces patient education, ensures information is documented while it is fresh in the clinician’s mind (ahem, accuracy), and is properly date- and time-stamped.

5. Implement a care transition model

Transitional care management (TCM) services are among the most straightforward strategies to implement. These models encompass broader frameworks and interventions to improve care transitions and reduce hospital readmissions.

Note: Medicare may cover some costs for transitional care services during a 30-day period.

Let’s take a closer look.

BOOST: Better Outcomes for Older Adults through Safe Transitions

Reportedly used by more than 180 hospitals, this care model helps administrators identify and understand weaknesses in their current transition and discharge procedures.

Administrators and their teams can implement tailored interventions to address these weaknesses, track their progress, and receive mentorship.

GRACE: Geriatric Resources for Assessment

The GRACE model specifically targets low-income seniors and works through interdisciplinary teams, coordinating care between patients’ primary care providers and GRACE support teams.

The model incorporates in-home assessments, care planning, a community services liaison, active case management, and weekly GRACE team meetings.

Reportedly, the GRACE model has been shown to improve the quality of care and health outcomes for low-income seniors, while remaining cost-neutral.

Project RED: Re-Engineered Discharge

This research-backed model, developed by the Boston University Medical Center, “has been proven to reduce rehospitalizations and yields high rates of patient satisfaction.” It is based on 12 components:

Ascertain need for and obtain language assistance.
Schedule follow-up medical appointments and post-discharge tests/labs.
Plan follow-up for pending lab tests or studies at discharge.
Organize post-discharge outpatient services and medical equipment.
Identify the correct medicines and a plan for the patient to obtain and take them.
Reconcile the discharge plan with national guidelines.
Teach a written discharge plan that the patient can understand.
Educate the patient about his or her diagnosis.
Assess the degree of the patient’s understanding of the discharge plan.
Review with the patient what to do if a problem arises.
Expedite transmission of the discharge summary to clinicians accepting care of the patient.
Provide telephone reinforcement of the discharge plan.

Bridge Model

This model utilizes social workers (master’s level education) as Bridge Care Coordinators (BCC). They manage the interdisciplinary team for discharge planning, interdisciplinary rounds, and bedside care visits (all pre-discharge).

Post-discharge, BCCs conduct assessments and interventions to connect patients with the necessary resources and providers to address all identified gaps.

Reportedly, participating sites consistently claim more than 20% reduction in readmission rates.

Naylor Model

Mary D. Naylor, PhD, RN, FAAN, developed her transitional care model (TCM), which leverages advanced practice registered nurses (APRNs) with “specialized knowledge” to meet patients before discharge, coordinate the discharge planning, conduct a home visit within 24 hours after discharge, and provide follow-up care for the following 2–3 months.

Research has shown a 30–50% drop in readmissions using this model.

6. Educate patients and their families/caregivers

Education is an essential factor for patient safety and recovery after discharge.

Patients need to have a thorough understanding of their diagnosis and condition, their dietary and movement restrictions, and the consequences of not following these restrictions. Patient education should also include clear instructions for medication dosages and frequency post-discharge.

Patients should be encouraged to ask questions when something is unclear or when they have doubts. This helps them become active participants in their own care, which can help with adherence and follow-through.

7. Medication reconciliation

Medication reconciliation is also a point emphasized by the Joint Commission (JC), highlighting its importance regardless of whether it’s tied to hospital readmission reductions.

Providers should compile a comprehensive list of all medications the patient has been taking, cross-reference it with all medications the patient has been administered during their hospital stay, and include all medications prescribed for post-discharge care.

This helps identify dosing errors, duplication, omission, and drug interactions.

8. Conduct patient follow-ups

In a systematic review of 15 studies, “Outpatient Follow-Up Visits to Reduce 30-Day All-Cause Readmissions for Heart Failure, COPD, Myocardial Infarction, and Stroke,” the authors found that outpatient follow-up visits can help reduce hospital readmissions significantly:

Reduced by 7% for COPD patients
Reduced by 20–27% for heart failure patients
Reduced by 24% for stroke patients

Follow-ups serve as reminders for patients to follow their treatment plan. They can also be opportunities for course correction and to assess any gaps in aftercare before complications arise.

9. Monitor hospital-acquired infections (HAIs)

Key measures include promoting hand hygiene among healthcare workers and patients, implementing infection control measures (e.g., personal protective equipment and isolation precautions), maintaining environmental cleanliness, and optimizing antimicrobial use to prevent antibiotic resistance.

By implementing evidence-based infection prevention practices, healthcare facilities can minimize HAIs, protect patients and healthcare workers, and improve overall healthcare outcomes.

10. Layered interventions

Many of these strategies can be combined or layered to optimize their impact.

Break efforts out into 3 phases:

During hospitalization

Identify the patient's risk level to determine where to focus discharge planning. (Chronic care? Socioeconomic status? Health literacy?)
Screen specifically for SDOH to determine barriers to after-care services. (Transportation? Housing? Food security?)
Ensure adequate nurse staffing to reinforce effective patient education throughout the patient’s stay, not just right before discharge.

At discharge

Have a pharmacist lead the medication reconciliation.
Have your nurses use the teach-back methodology to verify patient understanding.
Set a follow-up appointment instead of relying on the patient to call later and set it up.

After discharge

Leverage social workers or nurse case managers to engage in phone outreach to check in with patients.
If a patient no-shows for their follow-up appointment, find out why and try to reschedule.
Plan to invest more resources and time in high-risk patients.

Reducing readmissions is a coordinated effort

What is the most effective strategy to reduce readmissions?

Most of these strategies rely on sufficient resources and staff buy-in to be effective.

Any of these strategies, alone or combined, can have an impact, and yet their success relies on your team’s level of engagement with their work.

How do you get staff buy-in? Start by including them in the discussion and planning. Take a look at our tips for improving staff engagement.

Sources:

10 Strategies for reducing hospital readmissions

Add Your Credit Card

Key takeaways:

What are hospital readmissions?

How the CMS defines and measures hospital readmissions

Why are readmissions so important to hospitals?

What causes hospital readmissions?

How to reduce hospital readmission rates