Reducing hospital readmission rates and improving care transitions

In 2022, the Centers for Medicare & Medicaid services (CMS) fined over 2,200 hospitals for having too many hospital readmissions in Medicare patients within 30 days, according to KFF Health News.

According to a report from the Agency for Healthcare Research and Quality (AHRQ), Medicare patients account for 60% of hospital readmission rates – that’s 2.3 million older adults who end up back in the hospital within just 30 days of their last visit.

Readmissions are costly as well. The average patient’s readmissions cost was $15,200 in 2018, costing Medicare and the health care system billions of dollars annually.

For companies in the health care industry, these statistics mean higher acuity patients, higher costs and an increased need to reduce hospital readmissions.

Oftentimes, hospital readmissions are due to a lack of safe and effective transitions from the hospital to the home. In fact, approximately 25% of care transitions fail for a variety of solvable reasons.

That is why Enhabit Home Health & Hospice provides comprehensive oversight and compassionate care during transitions from one care setting to another. In doing so, Enhabit helps reduce hospital readmission rates, increase patient satisfaction and improve health outcomes.

Factors driving high hospital readmission rates

According to a landmark study published by the New England Journal of Medicine, 67% of Medicare readmissions are due to medication noncompliance. But that is just one factor among many.

Poor physical function at the time of discharge is also near the top of the list of contributing factors for readmission, according to a study from the Physical Therapy & Rehabilitation Journal.

An increases in the risk of readmission is associated with failure to improve physical function within 30 days of discharge. Yet, the study found that information about physical function is included in physician discharge summaries only 26% of the time.

Other key risk factors include:

• Underdeveloped discharge plans,
• Complex discharge instructions
• Inadequate communication with physicians
• Ill-prepared caregivers
• Inappropriate home environments

According to the aforementioned New England Journal of Medicine study, 50% of Medicare patients who are readmitted have had no interaction with a physician between discharge and readmission. Further, due to lack of collaboration between hospitals and providers, many primary care physicians (PCP) don’t even have access to their patients’ discharge summaries.

There are other factors leading to high hospital readmission rates, especially among patients nearing end of life.

Most of these problems are due to long-standing gaps in the home-to-hospital transition process. Most of these gaps are due to a lack of coordination and communication between the providers involved.

Closing the gaps in the hospital-to-home transition

Kristi Wimberly, vice president of care transitions at Enhabit, credits overcoming readmissions to a strong sense of collaboration.

“By taking a coordinated team approach to care, we give patients a safe and effective transition from the inpatient setting to the home,” Wimberly said. “Working with the patient’s entire team of experts helps us provide a post-acute solution for our hospital partners and also helps to get the patient the right service, at the right time.”

Although studies have shown a lack of coordination and communication between care settings, there are strategies being employed by leading health care organizations and institutions to help close the gaps in the hospital-to-home transition and enhance care in the home.

Improve communication and collaboration to reduce hospital readmissions

“Efforts to reduce hospital readmissions must begin before discharge,” Wimberly said. “Inpatient facilities must ensure that essential information, including functional status and patient-specific risk factors, is available to everyone on the care and discharge teams, and that there is close collaboration between them.”

Enhabit’s Care Transitions Program has a team of coordinators and navigators who help ensure the transition from hospital to home is successful. These clinicians focus on things like pre-admission drug regimen reviews, risk stratification of patients and on-site case conferencing.

Additionally, Enhabit focuses on collaborating and helping to fill the gaps between settings. They partner with discharge planners, provide fully integrated transitional services, coordinate follow-up appointments with PCPs and support patient adherence with post discharge regimens.

Expanding the role of rehabilitation professionals

Often, hospital discharge proceeds without the input of rehabilitation professionals, who specialize in post-discharge care. While they may be involved in recommending an acute or post-acute setting, they may not be involved in other critical conversations.

Increasing their role in the process can help ensure that patients are not only discharged to the best possible location, but that they receive the best possible care once there, according to Wimberly.

“Our care transitions coordinators (CTCs) and transition navigators (TNs) collaborate with the interdisciplinary care team to understand functional status, potential barriers to a safe transition and anticipated needs in the home setting,” she said. “Engaging in these conversations improves the continuity of care as our CTCs and TNs pass this information on to their clinical partners who will be providing care in the home.”

Increase focus on physical function

When functional information is ignored during the hospital-to-home transition, patients are often discharged to face a range of unmet care needs. These needs can range from the lack of durable medical equipment (such as a tub bench) to the lack of a caregiver to help with activities of daily living.

“To minimize hospital readmissions, discharge planning must include a heightened focus on this key determinant of successful or unsuccessful recovery and rehabilitation,” Wimberly said. “Our program focuses not only on the patient but the caregivers as well, prioritizing their understanding of how to care for the patient to achieve the best possible outcome.”

Leverage the power of home health

When properly integrated into the continuum of care, home health becomes a critical part of ensuring that patients discharged from hospitals or other inpatient settings don’t suffer relapses that require readmission.

Enhabit utilizes collaboration, predictive analytics and patient-centered care to help every patient meet their goals at every step of their health care journey. In addition to cutting costs, maintaining this approach to home-based health care helps to facilitate smoother transitions, reduced hospital readmissions and better outcomes for patients and their loved ones.