Discharge Planning to Reduce Hospital Readmissions

Address multiple factors for the best outcomes

Readmissions are estimated to cost $26 billion in the United States each year,[1] representing a significant burden on the healthcare system. Currently, 15% of patients covered by Medicare are readmitted to the hospital within 30 days of discharge, and 1 in 4 of these readmissions are potentially preventable.[2],[3]

A substantial portion of this burden falls on hospitals. Readmissions are often not reimbursed fully, especially if due to preventable complications.

The Hospital Readmissions Reduction Program (HRRP) reduces CMS payments by up to 3% for hospitals over the national averages for readmissions for six specific conditions:

●      Acute myocardial infarction (AMI)

●      Chronic obstructive pulmonary disease (COPD)

●      Congestive heart failure (CHF)

●      Pneumonia

●      Coronary artery bypass graft (CABG) surgery

●      Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)

A staggering 82% of hospitals had their payments reduced for fiscal year 2019 under this program.[4]

Readmission causes significant emotional impact on patients as well. Getting readmitted for a complication is hugely distressing. These factors highlight the urgent need for optimal discharge planning strategies to reduce readmissions.

The Root of the Problem: Factors That Lead to Readmission

A range of factors contribute to hospital readmissions, including:

●      Inadequate discharge education. Research has linked poor patient education to a 4.4% higher readmission rate.[5] For the best results when teaching, help patients learn multiple ways and provide reliable resources they can take home. The patient education materials from Patient Guide Solutions align with the most current recommendations from the leading healthcare societies.

●      Inadequate follow-up. Research in JAMA showed patients who did not follow up with their primary care physician seven days after discharge had a 5% higher readmission rate than those who did. A potential explanation is that 40% of patients are still awaiting diagnostic test results at discharge. These results often point to the need for interventions, leaving much to be missed without follow-up.

●      Medication errors. A fifth of all readmissions happen because of medication errors.[6]

Discharge Planning Strategies to Reduce Readmissions

Individualized Discharge Planning

Patients need information about their diagnosis presented in their preferred learning style for the best outcome. A recent meta-analysis of 17 studies found patients who received individualized discharge planning had an 11% reduction in readmissions.[7]

One condition warranting particular focus is CHF. Not only is CHF part of the Hospital Readmission Reduction Program, but more than 30% of patients hospitalized for heart failure are rehospitalized or die within three months of being discharged.[8]

The fluid-overload cycle is difficult to break. Patients taking diuretics to reduce their fluid load may be compliant in the hospital but often can't keep it up at home. In one study, researchers used a heart failure-specific discharge checklist to ensure the patient had:

●      Optimal fluid status

●      Correct prescriptions

●      Follow-up scheduled within seven days of discharge

This checklist resulted in a 13.3% reduction in 30-day readmissions.

Structured Discharge Plans

Structured discharge plans can follow established best practices and be individualized to the patient's needs. The RED (Re-Engineered Discharge) After Hospital Care Plan developed by the Agency for Healthcare Research and Quality (AHRQ) and Boston University Medical Center describes a structured discharge plan that can lead to a decrease in hospital readmission rates of 30%, studies say.[9]

Elements of the RED After Hospital Care Plan include:

●      Hospital discharge date, hospital contact information, and location

●      Information on who to contact with questions after discharge

●      An updated medication list, including instructions for taking new medications and side effects to watch for

●      A medication allergy list

●      A list and calendar of upcoming appointments for the next 30 days

●      A diagnosis information page

●      A list of outstanding test results to watch for

●      A list of medical equipment the patient needs to obtain

●      Advanced directives

●      Diet recommendations

●      Exercise and physical activity limitations

Multidisciplinary Team Approach

A multidisciplinary team model encourages clear communication between healthcare and social workers to help coordinate the patient's post-discharge needs. An interdisciplinary approach with a COPD care bundle helped one health system reduce COPD readmissions by 8%, suggesting a promising avenue to explore.[10]

Engage Family and Caregivers

Involving family members in discharge planning has a significant impact on readmissions. A family member can help:

●      Manage medications

●      Manage diet

●      Remind patients of physical restrictions

●      Assist the patient in the activities of daily living

●      Give patients rides to follow-up appointments

Post-discharge support

Post-discharge support can be through follow-up appointments, phone calls, or home visits. In one study, a 72-hour post-discharge follow-up call reduced 30-day psychiatric readmissions by 3.4%.[11]

For certain conditions, setting up patients with an outpatient multidisciplinary program can help too. One heart failure-specific cardiac rehabilitation program reduced admissions to the hospital by 25% after discharge.

Conclusion

Effective discharge planning is critical in reducing hospital readmissions and improving patient outcomes. When optimizing your discharge process, address team communication, medication management, caregiver involvement, targeted education, and post-discharge follow-up. A proactive approach to discharge planning not only reduces the financial burden on your hospital, but also contributes to improved patient satisfaction and overall well-being.

References:

[1] Wilson L. MA patients’ readmission rates higher than traditional Medicare, study finds. Healthcare Dive. Published June 26, 2019. Accessed November 3, 2023. https://www.healthcaredive.com/news/ma-patients-readmission-rates-higher-than-traditional-medicare-study-find/557694/

[2] Centers for Medicare and Medicaid Services. Hospital Quality Initiative Public Reporting. Accessed September 12,2023. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare

[3] Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176(4):484. doi:10.1001/jamainternmed.2015.7863

[4] Map: See the 2,599 hospitals that will face readmissions penalties this year. Advisory.com. Accessed November 3, 2023. https://www.advisory.com/daily-briefing/2018/09/27/readmissions

[5]  Becker C, Zumbrunn S, Beck K, et al. Interventions to improve communication at hospital discharge and rates of readmission: A systematic review and meta-analysis: A systematic review and meta-analysis. JAMA Netw Open. 2021;4(8):e2119346. doi:10.1001/jamanetworkopen.2021.19346

[6] El Morabet N, Uitvlugt EB, van den Bemt BJF, van den Bemt PMLA, Janssen MJA, Karapinar-Çarkit F. Prevalence and preventability of drug-related hospital readmissions: A systematic review. J Am Geriatr Soc. 2018;66(3):602-608. doi:10.1111/jgs.15244

[7]Gonçalves-Bradley DC, Lannin NA, Clemson L, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2022;2(2):CD000313. doi:10.1002/14651858.CD000313.pub6

[8] McNaughton CD, Cawthon C, Kripalani S, Liu D, Storrow AB, Roumie CL. Health literacy and mortality: a cohort study of patients hospitalized for acute heart failure. J Am Heart Assoc. 2015;4(5). doi:10.1161/JAHA.115.001799

[9] Jack BW. A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Ann Intern Med. 2009;150(3):178. doi:10.7326/0003-4819-150-3-200902030-00007

[10] Gentene AJ, Guido MR, Woolf B, et al. Multidisciplinary team utilizing pharmacists in multimodal, bundled care reduce chronic obstructive pulmonary disease hospital readmission rates. J Pharm Pract. 2021;34(1):110-116. doi:10.1177/0897190019889440

[11] Phillip A, Rossi G, DeSilva R. Stopping the revolving door: Reducing 30-day psychiatric readmissions with post-discharge telephone calls. Cureus. 2022;14(1):e21174. doi:10.7759/cureus.21174