Preventing Hospital Readmissions

Hospital readmissions are bad for patients—especially seniors who may already be weakened by multiple chronic disease. They cost tens of billions of dollars. They are not even good for hospitals (at least not top-quality facilities that regularly fill their beds).

About one in five Medicare patients are readmitted within 30 days, and one-third within 90 days, according to a New England Journal of Medicine study. Medicare alone spends $17 billion on these roundtrips annually, and private insurers spend uncounted more dollars. Patients most at risk suffer from pneumonia or other infections, congestive heart failure, or pulmonary disease.  

There is a growing movement to try to reduce readmissions, and the 2010 Affordable Care Act includes big penalties for hospitals that don’t get with the program. But figuring out how to keep patients with complex medical problems out of the hospital is not easy.

I was struck by just how hard when I saw a new consumer guide from the Agency for Healthcare Research and Quality, a highly regarded government agency. The booklet, called “Taking Care of Myself: A Guide When Leaving the Hospital”  is a checklist of what to know and what to do so you can care for yourself after discharge.

It is 16 pages long.

I’m not criticizing the AHRQ or the careful research by Brian Jack at Project Reengineered Discharge (RED) upon which the booklet was based. Indeed, the guide seems incredibly valuable and I’d recommend that health systems make it available to everyone they discharge.

But how is anyone, especially a frail senior, going to keep track of 16 pages of information? What medications do I take? What do I take them for? When do I take them? Who are my doctors? When is my next appointment? What questions should I ask? This is overwhelming for an 80-year-old widow, especially if she is suffering from some dementia. 

Increasingly, hospitals are coming to recognize that many patients can’t manage their post-acute care without help. And I don’t just mean the assistance of a nurse or nurse’s aide with managing medical devices, changing bandages, or even help bathing or toileting. I also mean help organizing their care. 

No longer will a facility’s responsibility for patients end when they role out the front door at discharge. Keeping them from returning to the ER will require hospitals (and skilled nursing and rehab facilities) to take on some important new roles. They include:

  • Working with patients on their discharge plan at admission. Don’t wait until an hour before discharge.
  • Learning about the patient’s home situation. Is she physically and cognitively able to care for herself? Does she have a family member who can help her? Does she have neighbors, friends, or members of her church or synagogue who can help?
  • Determining whether palliative care or hospice is appropriate.
  • Determining whether a care manager is appropriate
  • Identifying those patients most at risk of readmission and assigning them a nurse or social worker who can work closely with them once they have returned home. We have now seen the results of several transitional care demonstrations. Done right, they work.

All of these initiatives cost up-front dollars that are rarely reimbursed by Medicare or private insurance.  Eventually, the new health law should provide mechanisms to pay for them. For now, hospitals and nursing facilities will have to eat the cost. But it is the right thing to do, and I’m convinced it will pay off, in terms of both patient care and controlling costs.

By | 2011-03-30T19:42:49+00:00 March 30th, 2011|Care Coordination, Hospitals, Medicare|8 Comments


  1. Patrick Roden April 1, 2011 at 12:12 am - Reply

    Howard I couldn’t agree with you more. I can’t tell you how many times when discharging a patient I feared for their safety at home. And waiting to give instructions at the time of discharge is less than optimal; they should be re-enforced at that time (after multiple exposures to the plan during the course of their stay).

    Patients and families are always anxious to get home, and care providers are rushed to take care of the next patient who fills the bed that is still warm from the last discharge—instructions can be rushed and it isn’t always the best teaching moment. I know that discharge planners do a much more thorough job.

    Often the person picking the patient up (“their ride”) isn’t a relative and won’t be home with the patient even short-term; or it’s an elderly spouse and questionable how much they understand.

    You have once again identified a lack of Systems Thinking in the system, and it leads to poor patient outcomes and frequent re-admissions at great cost and hardship.
    Your problem areas are spot on, as are your potential solutions.

  2. Shannon-Aging Wisely LLC April 7, 2011 at 8:12 am - Reply

    Great article, Howard! An issue that I too am passionate about. We covered this topic in series on both of our blogs ( & in Feb., specifically tips for family caregivers & patients.

    From a system perspective, you are right on about the issues and solutions. Hopefully we will be there one day in the not-too-distant future. In the meantime, I’m also passionate about educating families about this issue, so they can get a jump on the planning from admission time and not be shocked when they realize the flaws in the current process.

    We also include the sample PASS discharge form in our posts, which is a ONE page form so a lot easier to manage. However, that’s only one piece of the puzzle as you mention. I can’t imagine handling my own post-surgery instructions/care without a lot of help as a very healthy young woman with lots of experience navigating healthcare…how do we expect 80+ year olds with multiple conditions (and sometimes cognitive problems)and little support to do well?

  3. Diane Doumas April 7, 2011 at 1:55 pm - Reply

    As a senior living operator for over 25 years, I would also like to see a more robust discharge plan that includes “systems thinking” and more innovation. During this critical time of discharge there are innovative solutions available that support preventive, proactive care to intervene before the rehab/healing process gets off track.

    You mentioned CHF, for example. By trending the quality of sleep, looking at time spent in bed and restlessness levels, subtle changes in the disease process can be caught early for proactive intervention. The low cost of this type of unobtrusive “smart sensor” technology is minimal when compared to the cost of relapse and recurring hospital visits, which may ultimately result in the need for costly long-term care.

    The largest study of its kind is underway to demonstrate the value of advanced technology to reduce cost and improve quality of care. If these wellness solutions are eventually approved for coverage, perhaps they will be included as part of a more robust discharge plan.

  4. Robert Griesemer RN, BSN, MS April 8, 2011 at 10:43 pm - Reply

    The solution to prevent or greatly reduce re-admissions is really quite simple. The hospitals should contract with Professional Geriatric Care Managers, of which I am one in Elm Grove Wisconsin. For a nominal fee, I as well as others would f/u with the recently discharged person, screen them over the phone, set up a visit within a few days after their discharge and then again at a designated time depending on history and initial findings. The hospital would, with permission get a status report and a predictability quantum numeric, i.e. probability for re-admission. During the visit, the PGCM would conduct a head to toe assessment, medication review, home/family support system evaluation, safety analysis, etc. Should the individual wish to continue PGCM services after the hospital-PGCM contracted time allotted has been fulfilled, that individual would pay privately thereafter. After one visit a good PGCM is going to identify non-compliance related to medications, f/u with physician, as well as determine status indicating need for physician intervention. A simple solution if hospitals truly want to prevent re-admissions.
    Robert Griesemer RN,BSN,MS
    Professional Geriatric Care Manager

  5. Siva Subramanian June 28, 2011 at 10:10 pm - Reply

    Dr. Gleckman – Great article. Clearly AHRQ or RED has done their part to highlight what is needed to reduce the likelihood of a readmission (or even the ED visit). However as you point out the problem with these long (or even short) checklists are they are too generic and require the patient or caregiver to think through and understand each item which may be beyond their ability for a variety of reasons. Patient-specificity and Simplicity are key to this.

    At the end of the day, I agree, the hospital MUST take charge of this problem and address this from the time of admission through discharge and beyond. Our software solution for hospitals, Carebook does exactly this by leveraging collaboration across providers and communication with patients/caregivers. Carebook incorporates checklist tools (from Project BOOST or IHI) and dynamically customizes it for each patient giving providers and patients just what they need. It also enforces every point you highlight across the transition continuum – d/c planning from time of admission, patient risk assessment, patient readiness for d/c, provider readiness for d/c, patient-specific aftercare plan generation, communication to aftercare providers and finally automated follow-up for patients and caregivers. We are in trials at a west-coast hospital and will soon be releasing data from it. For more information, please feel free to contact me –

  6. October 4, 2011 at 10:49 pm - Reply


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  7. interesting poll question January 31, 2012 at 9:05 pm - Reply

    interesting poll question…

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