Assignment: Reducing Hospital Readmission

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Assignment: Reducing Hospital Readmission

Assignment: Reducing Hospital Readmission

Assignment: Reducing Hospital Readmission

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Week 2 – Assignment 1 Discussion Melynk and Fineout-Overholt (2011) note that there are seven steps to the evidence-based practice (EBP) process. The first step is to cultivate a spirit of inquiry. To encourage this spirit of inquiry, you are asked in this discussion to: Briefly describe the problem or issue that you have decided to be the topic for your project proposal in order to orient your classmates and faculty Indicate how it relates to your area of specialization State your PICOT question. Indicate in parentheses after each segment, what part of PICOT the preceding words represent. For example: In patients recently discharged from the hospital following care for heart failure (P), do hand-off calls by the nurse to the primary care provider using the SBAR format (situation, background, assessment, recommendation) (I) compared to no calls (C) decrease readmission rates (O) over a one year period (T). Discuss which process model resonates with you and will help keep you focused during the project. Process models included in your text (Melnyk & Fineout-Overholt, 2011) are: Clinical scholar model Stetler model of evidence-based practice Iowa model of evidence-based practice to promote quality care Model for evidence-based practice change by Rosswurm and Larrabee Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model Provide feedback to your classmates that focuses on: The use of correct PICOT format for the question to guide the literature search. Does the question reflect a clinical research question or one appropriate for an evidence-based practice project?

Assignment: Reducing Hospital Readmission


Readmissions are already one of the costliest episodes to treat, with hospital costs reaching $41.3 billion for patients readmitted within 30 days of discharge, the Agency for Healthcare Research and Quality (AHRQ) .

The financial burden of hospital readmissions also recently increased as value-based reimbursement models replaced fee-for-service payments, especially for Medicare.

Medicare beneficiaries contributed the most to high hospital spending on readmissions. Hospital readmissions cost Medicare about $26 billion annually, with about $17 billion spent on avoidable hospital trips after discharge, according to  from the Center for Health Information and Analysis.

With hospital and federal dollars going to hospital readmissions, CMS created a value-based reimbursement program that penalizes hospitals for excessive readmission rates for six conditions, including chronic lung disease, heart attacks, and hip and knee replacements. The Hospital Readmissions Reduction Program (HRRP)  rates by 8 percent nationally between 2010 and 2015.


However, decreasing hospital readmission rates through the program came at a price for some hospitals. CMS  over 2,500 hospitals by more than $564 million in 2017 for excessive 30-day hospital readmission rates.

And Medicare isn’t the only payer pressuring hospitals to prevent hospital readmissions. Readmissions of privately insured and Medicaid beneficiaries cost $8.1 billion and $7.6 billion, respectively, AHRQ found.

To combat growing costs, payers across the industry are adding hospital readmission quality measures to their value-based reimbursement programs. Hospitals engaging in any model are likely to face penalties if their providers cannot improve hospital readmission rates.

Hospitals can reduce readmission rates and avoid value-based penalties by identifying causes of readmissions, optimizing transitional care, and improving patient engagement.


Understanding why a patient returns to the hospital after discharge is key to preventing readmissions and solving challenges of follow-up care.


AHRQ  the top conditions contributing to hospital readmissions. For Medicare readmissions, the conditions included:

• Congestive heart failure, non-hypertensive, with 134,500 30-day readmissions• Septicemia, not including labor, with 92,900 readmissions• Pneumonia, not caused by STIs or tuberculosis, with 88,800 readmissions• Chronic obstructive pulmonary disease and bronchiectasis, with 77,900 readmissionsREAD MORE: 

• Cardiac dysrhythmias, with 69,400 readmissions

Medicaid readmissions stemmed from different conditions, with most relating to behavioral and mental health issues. The top conditions contributing to readmissions included mood disorders, schizophrenia and other psychotic disorders, diabetes mellitus, pregnancy, and alcohol-related disorders.

Chemotherapy or radiation maintenance topped the list of conditions causing privately insured readmissions, followed by mood disorders, surgical complications, device, implant, or graft complications, and septicemia.

Identifying patients at risk for these conditions is a good place to start. Data analytics and  tools are crucial to pinpointing which patients are the most likely to end up back in the hospital after discharge.

But hospitals should also seek other reasons why patients return to the hospital. Housing instability, food insecurity, transportation challenges, and other social determinants of health may also spur patients to seek hospital care after discharge,  Byran Cote, Managing Director at Berkeley Research Group.

“Are they really there for the hip fall? Are they are really there because they did fall and broke their hip or shoulder, or what’s really driving it? Is it anxiety, dementia, or depression?” he asked.

If such questions are not addressed, the patient will likely experience another fall, he added.

Hospitals should develop social determinants of health screenings to identify patients at risk for hospital readmissions. About 88 percent of hospitals screen patients for social needs, Deloitte recently .

However, only 62 percent of the organizations screen systemically or consistently.

Implementing social determinants of health screening protocols can help hospitals pinpoint patients at high risk for readmissions before the patient is discharged. Connecting patients to in-house or community-based supports prior to the initial hospitalization is key to keeping patients out of the hospital after discharge.


Ineffective care transitions following a hospitalization increase the rates and costs of hospital readmissions. Inadequate care coordination, such as lackluster care transition management, accounted for $25 to $45 billion in wasteful spending in 2011, Health Affairs .

Communication breakdowns drive ineffective care transitions from the hospital to post-acute care or home settings, the Joint Commission . Technological and cultural barriers prevent providers from sharing information among themselves and caregivers.

The commission also pointed to accountability breakdowns as a contributor to poor care transitions.

“In many cases, there is no physician or clinical entity that takes responsibility
to assure that the patient’s health care is coordinated across various settings and among different providers,” the commission wrote. “Providers – especially when multiple specialists are involved – often fail to coordinate care or communicate effectively, which creates confusion for the patient and those responsible for transitioning the care of the patient to the next setting or provider. Primary care providers are sometimes not identified by name, and there is limited discharge planning and risk assessment.”

The accountability challenge causes patients and other providers to receive insufficient knowledge and resources for at-home or post-acute care.

To overcome communication and accountability challenges, hospitals have used “transition coaches” who are primarily nurses and social workers to help create and guide post-discharge care. These coaches are usually the single point of care for patients.

A model widely used by hospitals is the . Eric Coleman, MD, MPH, developed a program that uses a nurse or nurse practitioner as a transition coach to manage post-discharge care.

The transition coach performs a home visit within 72 hours of discharge and follows up with patients through phone calls or home visits over the next four weeks. The coaches help patients manage medications, schedule follow-up care, recognize and respond to symptoms or signs of worsening condition, and complete a personal health record.

A Colorado-based health system reduced 30-day hospital readmissions by 30 percent and 180-day readmissions by 17 percent after implementing the Care Transitions Program, Health Affairs. The program also decreased average costs per patient by almost 20 percent.


Inadequate patient and caregiver communication is another barrier to effective care transitions and hospital readmission reduction initiatives, the Joint Commission stated.

“Patients or family/friend caregivers sometimes receive conflicting recommendations, confusing medication regimens, and unclear instructions about follow-up care,” the commission explained. “Patients and caregivers are sometimes excluded from the planning related to the transition process. Patients may lack a sufficient understanding of the medical condition or the plan or care. As a result, they do not buy into the importance of following the care plan, or lack the knowledge or skills to do so.”

Failing to include patients in the discharge process results in higher hospital readmission rates, studies show. Patients who reported that they were not involved in their care during the original encounter were 34 percent more likely to experience a readmission, a recent Patient Experience showed.

In addition, patients who did not report receiving written instructions for discharge care were 24 percent more likely to face a readmission.

Neglecting to integrate caregivers into discharge planning also spells trouble for hospital readmission rates. The chance of a 90-day readmission fell 25 percent and 180-day readmission declined 24 percent when providers engaged caregivers in discharge planning, a research team from University of Pittsburgh Medical Center recently .

Hospitals can improve caregiver and patient engagement by educating patients about follow-up care. Providers should make time for patient questions during the hospitalization and employ methods such as  in which providers explain conditions, treatment options, and self-care instructions to patients and patients repeat the information back to providers.

Reminding patients of follow-up care appointments is also critical to reducing avoidable hospital readmissions. Providers should discuss what follow-up care entails and why it is important, as well as  patients to remind them of upcoming appointments.

Offering  may also help hospitals to cut down on readmissions. Health systems such as MedStar Health have partnered with Uber, Lyft, and other ridesharing companies to provide rides to patients.

Helping patients attend their follow-up care can help providers to catch warning signs before the patient presents to the emergency room.

Hospital readmission rates can cost hospitals, especially in a value-based reimbursement environment. Reducing how many patients return to the hospital after discharge will not only improve patient outcomes, but boost bottom lines.

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