Solving the high rates of hospital readmissions

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

  • Identifying high-risk patients early
  • Educating the patient and involving family members
  • Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

Comments are moderated before they are published. Please read the comment policy.

  • Concerned Health Nut

    I’ve been reading posts on various topics for quite awhile and finally writing my first-ever posting. Really enjoy this site & have the utmost respect for all the providers here. I’m an RN Case Manager with an insurance company (don’t shoot me!) who has a primary role to keep patients from readmitting needlessly, using the ER as a doctor’s office, etc. I find that working for them is a double-edged sword in that we do a lot of good work for many patients and, personally, I’ve educated more than a few on their disease processes. With that said, I completely agree that patients DO admit more as their disease(s) progresses. Common sense, yet we are constantly having a finger pointed at us – “Why can’t you do more to keep Mrs. Smith out of the hospital?” Ridiculous…perhaps one of the answers is to make the hospitals LESS like hotels and patients wouldn’t be so eager to be admitted (I know, wishful thinking).

    • whoknows

      Don’t worry. We won’t shoot you. But it ‘s kind of sad that the insurance company has to hire you. In the ideal world it would be nice if you could work in a PCP or geriatrician’s office. Less admins involved and all for direct care. You could do a whole lot more if you were actually working directly for these pts and following them under the care of their physician. Wishful thinking. i know. Thanks for responding. Welcome aboard.

      • Concerned Health Nut

        Thanks – appreciate it! I would prefer to work directly for my patients in a PCP office. This was the alternative to the hectic pace of bedside nursing. I’m also a Registered Dietitian so likely they figured they were getting two for the price of one. One of the main things I’ve been focusing on now is teaching patients to be “better” patients; what questions to ask, focusing on 1-2 complaints at a time, etc. I’ve been advocating for the providers as well to help reduce some of the admin time that you mentioned. Thanks for responding.

      • buzzkillersmith

        Practicing geriatrics is a fork in the eye. Tough gig.

    • Earth Angels INC

      Hospital re admissions can be reduced with better discharge planning and allocating the ideal home health care company. Having qualified clinicians going to a patient’s home can help the health care team better assess the patient’s environment and help educate and empower the patients and their caregivers to make the needed changes. Improved communication between case managers and home health clinicians can also reduce the burden of frequent readmits because in most circumstances it can be a situation that can be handled on an outpatient basis.

      • medicontheedge

        Show us the money, first of all. And there is the real fact that some patients and families are unable or unwilling to invest the time and effort into becoming managers and providers of care.

        • C.L.J. Murphy

          I agree. There is no shortage of potential solutions which might work “in a perfect world”, but the sad fact is that many of our sickest patients who are most likely to be readmitted are not residents of that “perfect world”, especially when it comes to family support and family members willing and able to step up as caregivers.

  • buzzkillersmith

    I agree that the problem is multifactorial. The idea that docs and nurses are able to keep pts that are sick, super sick, out the hospital is unrealistic without a robust outpt infrastructure. An experienced doc to run the collaborative team would be a plus, wouldn’t it? Good luck with all that.

    Case managers, social workers and so on are very helpful as well.

    But you can’t keep super sickies out of the hospital–at least with the resources thus far devoted. Maybe not even if the resources are available for many of the super sickies.

  • southerndoc1

    Old people with chronic medical problems get sick a lot. Maybe this phenomenon of readmissions is a fact of life and not a “problem.”

    • medicontheedge

      We can’t “fix” old. A recent article here proclaimed that we no longer allow people to die of old age.
      Now, I am not saying we should let people die…. Just that at some point the repetitive, futile and expensive interventions are nothing more than torture.
      Patients can only be “educated” to the level that THEY themselves, and their family/caregivers are willing and able to perform. It s ridiculous to think that the medical establishment can fix all of those problems!

  • maggiebea

    These are all great points. Omitted from this picture is the role of nursing homes in the frequent readmission of their longtime patients. Sometimes it looks as though the nursing home transports patients any time they catch cold, if only to prevent them from overburdening the already stretched nursing home staff.

    • medicontheedge

      Spot on! The average person is under the mistaken notion that “nursing homes” actually provide medical care. They exist only to provide the bare minimum to meet “standards”. The few RN’s that are actually there pass meds. The turning and watering is provided by underpaid and understaffed aides. (Bless their hearts). Like you said, the poor client is transported out, often against their will, for conditions that should and could. be taken care of there. Total reform of nursing homes, where clients are cared for IN PLACE needs to happen. But the corporations that run these chains will not let that happen… Their profit margin is slim enough already.

  • Pauline Lambert Reynolds

    Wouldn’t it be more cost effective to keep at risk patients in the hospital for one or two more days, eliminating the whole readmission process?

    • Becky

      It sure would! Wish my insurance company would’ve approved another night so I wouldn’t have been discharged with a dural leak (see my earlier comments) and have to get readmitted. The emergency room admission fee was over $600, (just the admit. Fee to walk into the ER) so the insurance company might as well have paid for another night.

  • Bob

    In this age of specialists and aging elderly, all systems are not go on most geriatric patients but specialists work on only one and seem not to recognize systems interact with each other.
    And every doc is as set in their ways as the patients except the Docs do not feel they learn anything from patients and some tend to not listen too closely. 2 way listening and asking can work wonders.