Academic journal article Frontiers of Health Services Management

Improving Transitions to Reduce Readmissions

Academic journal article Frontiers of Health Services Management

Improving Transitions to Reduce Readmissions

Article excerpt


Delivering high quality healthcare requires crucial contributions from many parts of the care continuum. However, as healthcare becomes increasingly specialized, coordination between providers and between settings is too often not conducted as a team effort. In the hospital setting, poor coordination of care often results in hospital readmissions, many of which are avoidable. In this article, we describe processes that hospitals can implement immediately to dramatically improve care transitions and reduce re-hospitalization rates. Readmission rates are a focus of interest for payers and policymakers seeking to promote efficiency and quality. Hospital executives may want to prepare their organization to excel on this performance metric in anticipation of payment, policy, and/or other forecasted changes in the market.

In a recent conversation with the chief medical officer at a large health system in the United States, the physician executive relayed stories about his own recent hospitalization for an emergency surgical procedure. He was mostly delighted with the care he received, but, when asked if he had experienced any surprises, he responded this way: "The pain was a surprise-mostly because each nurse seemed to have his or her own theory of pain management. Some predicted and managed pain aggressively, and others 'followed the orders' to the letter, even when I was in severe pain, without consulting the surgeon. The biggest surprise was at home. I was alone, fearful, uninformed, and disconnected. I had no real education on how to care for myself and no way to reach out for information, guidance, consolation, and care. I thought maybe it was because I am a physician, but now that I am sensitive to this, I see this failure happening everywhere."

In a December 2000 speech, Don Berwick, president and CEO of the Institute for Healthcare Improvement, labeled "discharge" a dirty word-associated generally with unpleasant ideas and images. A large majority of patients discharged from the hospital fail to receive the basic and necessary planning and preparation. One study found that 81 percent of patients requiring assistance with basic functional needs failed to receive a home care referral, and 65 percent said no one at the hospital talked to them about managing their care at home.1 These gaps lead to readmission in a surprisingly large number of cases. The costs associated with hospitalization consume nearly onethird of the total dollars spent on healthcare in the United States.2 A large body of experience and evidence suggests that, among the population of individuals who are hospitalized and re-hospitalized with high frequency, many hospitalizations are avoidable.3

Our experience suggests that by improving care transitions, hospitals can achieve lower readmission rates. In this article, we will outline the broad categories of failures in transitions, describe the Institute for Healthcare Improvement's (IHI) approach to reducing 30-day re-hospitalization rates, and describe our experience coaching teams working to reduce re-hospitalizations. We believe that hospital executives-through direct influence on institutional procedures and processes-can have a significant influence on re-hospitalization rates.


Readmissions represent, in some cases, a defect in hospitals' planning and care processes, or in the ambulatory support system, or in the community. By focusing improvement effort on the crucial transitions between different care settings, leaders can improve the care they provide to a large number of patients.

The increasing cost of healthcare is prompting payers and purchasers to focus scrutiny on high-cost areas that yield low quality. Attention is heightened in the current economic climate, because the search for potential savings is a high priority. Therefore, for economic and fiscal reasons alone, readmission rates are increasingly a focus of attention for healthcare executives, payers, and policymakers. …

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