A hospital readmission happens when a patient goes back to a hospital for treatment within a certain time after leaving. Most often, this time is 30 days, but sometimes it can be tracked at 90 days or even one year. Readmissions are worrisome when they could have been stopped. This can show there were problems in how care was given, how providers talked to each other, or how the treatment was planned.
Readmissions cause extra costs for hospitals and insurance providers. In 2010, the Centers for Medicare and Medicaid Services (CMS) started using readmission rates to decide hospital payments as part of a health law called the Affordable Care Act (ACA). The CMS Hospital Readmission Reduction Program (HRRP), which began in 2013, fines hospitals if their readmission rates are higher than expected for some conditions, like heart failure, heart attacks, and pneumonia.
From 2007 to 2015, Medicare data showed that readmissions for certain conditions went down from about 21.5% to 17.8%. For other conditions, rates dropped from 15.3% to 13.1%. Even with this progress, about 20% of patients still get readmitted. This shows hospitals face difficulties in making sure patients get good follow-up care, understand their medicines, and get proper education.
Studies also show that only 12% to 34% of summaries about a patient’s hospital stay reach the outside doctor before the patient’s first check-up after leaving. This causes more problems in continuing care.
Care transition programs try to make the move from hospital to home smoother by giving patients support. These programs usually include teaching patients about their health, checking medicines, setting up follow-up visits, and sometimes involving a team of different health workers. These programs have helped lower readmissions, especially for older people with complicated health problems.
One well-known program, the Care Transitions Intervention (CTI), connects patients with nurse coaches after discharge. Research showed CTI reduced 30-day readmission rates from 11.9% to 8.3% and 90-day readmissions from 22.5% to 16.7%. This shows it makes a difference.
Also, teams made up of nurses, pharmacists, and case managers give clear instructions about medicines and care. This has helped lower hospital visits after discharge from 44% to 31%.
Pharmacists play an important role in managing medicines when patients leave the hospital. Since errors with medicines often cause problems and readmissions, pharmacists focus on talking with patients and carefully checking their medicines.
A review of 123 studies in the U.S. from 2013 to 2022 found that almost 90% of pharmacy-led programs lowered 30-day readmission rates by an average of 7.4%. In these studies, 96.7% included patient counseling and 90.2% involved medicine checks. Many studies looked at patients with conditions that CMS HRRP covers, such as heart failure and pneumonia. This shows a focus on patients at higher risk.
An example is a tele-health program at Memorial Healthcare System. They made 801 phone calls and solved 94% of medicine problems found. This program cut 90-day readmissions from 35% down to between 10% and 17%.
Teaching patients is very important for lowering readmissions. Good education helps patients understand their illness, medicines, follow-up visits, and warning signs that need doctor attention. Family members can also help the patient stick to the plan.
Research shows that when patients and families are involved, they follow their care plans better and have better results. Patients who understand their care are less likely to return to the hospital without needing to.
Social factors can affect a patient’s ability to follow their care plans. Problems like no transportation can stop patients from going to appointments. Unstable housing can make storing or taking medicines hard. Lack of food can affect how well they heal.
Care transition programs that include social support or work with community groups can help with these issues. Taking care of social needs is important to reduce readmissions that could be avoided.
Hospital leaders and IT managers can use artificial intelligence (AI) and automation tools to make care transitions easier and improve patient results.
AI can help with front-office tasks like appointment scheduling, reminders, and calls to patients. This lowers the work for staff and helps patients get timely follow-ups after discharge.
AI can also look at electronic health records (EHRs) to find patients who are more likely to be readmitted. Knowing this early lets hospitals give these patients extra help, such as nurse coaches or pharmacist counseling.
For example, Simbo AI makes AI phone systems that handle post-discharge calls well. They remind patients about medicines, appointments, or warning signs. These systems can also quickly report patient problems to staff so they can stop hospital visits that could have been avoided.
Besides talking to patients, workflow automation helps teams by putting together patient data, hospital summaries, medicine lists, and appointment schedules. This closes information gaps and improves care handoffs between hospitals and doctors outside the hospital.
Health administrators and owners need to use care transition programs that include nurse coaching, pharmacy-led help, and patient education to lower readmission rates, meet CMS quality rules, and avoid fines from the HRRP.
IT managers have an important job to set up systems that support these programs well. AI tools and automation can improve office work, patient communication, and team coordination. Using these tools can help with better follow-up, medicine management, and fewer readmissions.
Also, investing in telehealth and remote monitoring lets care teams stay connected with high-risk patients after they leave the hospital. This helps with quick support that keeps patients from coming back to the hospital.
Medical practices in the United States that use these care transition methods can improve patient health and reduce costly hospital readmissions. Combining personal care with AI and automation can lead to better and more efficient healthcare after patients leave the hospital.
A hospital readmission occurs when a patient is discharged from a hospital and then readmitted within a specified time frame, commonly 30, 90 days, or 1 year.
Hospital readmissions pose challenges by increasing healthcare costs, straining resources, and indicating potential suboptimal care.
Approximately 20% of Medicare beneficiaries experience readmission within 30 days of discharge.
Preventable readmissions often result from inadequate communication during handoffs, medication issues, and premature discharge.
Strategies include improved discharge planning, medication reconciliation, patient education, post-discharge follow-up, and care coordination.
Medication reconciliation ensures patients understand their prescriptions, minimizing errors that could lead to readmission.
Social determinants, like transportation or housing instability, can affect patients’ ability to adhere to treatment and follow-up, increasing readmission risk.
Care transition programs provide structured support and education during the hospital-to-home transition, significantly reducing readmission rates.
Comprehensive patient education enhances understanding and adherence to treatment plans, reducing the likelihood of readmissions.
Recent efforts have decreased readmission rates from approximately 20% to about 15% in certain patient populations, indicating improved discharge practices.
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