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Learning About 30-Day Readmissions From Patients With Repeated Hospitalizations | Page 3

Published Online: June 27, 2014
Jeanne T. Black, PhD, MBA
Many of the recommended approaches have been those that can be implemented by hospitals alone, such as improving inpatient education and discharge instructions, medication reconciliation, making a timely postdischarge follow-up physician appointment, prompt transmission of the discharge summary to the patient’s primary physician, and postdischarge phone calls to patients. Much of the evidence regarding the effectiveness of these strategies, however, lacks rigor and/or consists of single institutions’ descriptions of quality improvement projects.16-19 While these interventions have not achieved noticeable reductions in total readmissions, it is possible they may be sufficient for some patients who do not have a prior history of readmissions. This is an empirical question that has not been addressed, because nearly all assessments of readmissions have focused on the occurrence of a single 30-day readmission, without considering prior hospitalizations or readmissions that occur beyond the 30-day period.

A better strategy to reduce overall 30-day readmission rates may be to identify patients with multiple hospitalizations and stop their cycle of repeated readmissions. The best opportunity for doing this may be found with individuals in the subgroup that has a moderate number of readmissions. In the medical center, these patients were older, with a high proportion dually eligible for Medicare and Medicaid. They may benefit from the Patient Centered Medical Home approach to assure that their multiple medical conditions are addressed, including mental health issues; care is coordinated among specialists and across sites of care; polypharmacy is managed; and patients and caregivers are engaged as partners in their care. Other approaches to reducing readmissions in this subgroup are better coordination between hospitals and skilled nursing facilities,20 improved transitional care that incorporates elements of the integrated geriatric care model,21 and greater access to services that identify and address patients’ functional limitations.22

This analysis suggests that achieving lasting readmission reductions would be the most challenging and resource- intensive among the very frequent users. Patients in this subgroup may have multiple comorbidities that are difficult to manage. They are more likely to be members of minority groups, to be non–English-speaking, and to have Medicaid insurance, all of which makes accessing non-hospital care difficult. Thinking more holistically may help the people in both frequent readmission subgroups. This could include expanding the boundaries of traditional hospital social work services to address issues such as food insecurity and housing-related problems that increase the risk of morbidity and need for medical care services.23,24 There is also growing recognition that if clinicians encourage discussion of patient goals and educate patients and families about options, they may choose supportive care rather than repeated acute care interventions.25

The very frequent readmission group also includes individuals whose medical problems are complicated by substance abuse and/or mental illness. This is the highrisk population targeted by the Camden Coalition.26 Reducing readmissions and improving quality of life should be possible for many of these patients, but it will require hospitals to do the hard work of initiating and sustaining relationships with other community-based organizations.7,17 There is also the possibility that appropriate interventions may not yet exist for some patients with complex problems. New community resources may be required, such as partial hospitalization/day programs, rehabilitation programs, transitional living centers for medically fragile patients, etc. Finding the resources to make such community investments will be difficult, especially while the dominant fee-for-service reimbursement model means that savings from reducing hospital utilization flow to payers and not to providers or communities.

This study has a number of limitations. First, the data are drawn from a single large urban teaching hospital that serves as both a referral center and a community hospital. As a result, the findings may not be relevant to smaller, non-urban hospitals. Patients whose only hospitalizations were for surgical MS-DRGs were excluded, so “index” admissions in the cohort may have been preceded by other hospital stays within the prior 6 months. Only readmissions to the same medical center were captured. Therefore, total hospital utilization by patients with very frequent readmissions is likely to be understated; because a larger proportion lived outside of the medical center’s primary service area, they may have sought additional care from other hospitals near where they live. Like other analyses based on administrative data, this study could not investigate the association between readmissions and personal characteristics such as functional status, social support, food insecurity, access to transportation, or neighborhood resources, which may be even more important determinants of readmission patterns than patients’ basic demographic or diagnostic profiles.

CONCLUSIONS

Patients with frequent admissions represented a small proportion of all adult medical patients but accounted for the majority of 30-day readmissions. Therefore, a focus on these patients is an important component of efforts to reduce hospital readmissions. Patients with a pattern of repeated admissions differ from other patients in significant ways that suggest different approaches to care management, transitional care, and community-based services may be needed.

Take-Away Points

Most 30-day readmissions are experienced by patients who experience frequent hospital stays.

  • Efforts to reduce readmissions must look beyond the current focus on a single hospital discharge and 30-day transition period.

  • Commonly recommended transition care solutions may not be sufficient to prevent many readmissions.

  • Patients with frequent readmissions are more likely to be members of minority groups, to be non–English-speaking, and to have Medicaid insurance, along with complex medical problems complicated by mental illness or substance abuse.

  • Reducing readmissions among the most complex patients is likely to require new forms of care in the community.
Author Affiliations: Cedars-Sinai Medical Center, Los Angeles, CA.

Source of Funding: None reported.

Author Disclosures: Dr Black reports employment with Cedars-Sinai Medical Center which, like all hospitals, is subject to the penalties of the Hospital Readmission Reduction Program.

Authorship Information: Concept and design; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis.

Address correspondence to: Jeanne T. Black, PhD, Cedars-Sinai Medical Center, 6500 Wilshire Blvd, Suite 1220, Los Angeles, CA 90048. E-mail: Jeanne.Black@cshs.org.
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Issue: June 2014
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