If hospitals are to reduce readmissions, it’s essential for them to partner with organizations in the community that provide post-acute care, says Teresa Marshall, RN, MS, CCM, senior managing consultant for Berkeley Research Group.

“When hospitals and community providers work collaboratively to identify and manage patients, they can partner to make sure that patients receive quality, cost-effective care that helps them recover and avoid hospital readmissions,” she adds.

Every hospital is unique and must develop its own plan, Marshall states. “The success of any readmission reduction initiative depends on each hospital’s financial state, hospital leadership, hospital culture, and priorities,” she says.

To be successful in improving care and reducing costs, case managers should understand the root causes and patterns of readmissions, says Amy Boutwell, MD, MPP, president of Lexington, MA-based Collaborative Healthcare Strategies.

When patients are readmitted, case managers or social workers should sit down with the patient and family and conduct an in-depth assessment to find the root cause for readmission. Many organizations develop a database to track the reasons for readmissions, and determine what can be changed to avoid readmissions in the future, Marshall says.

“It’s important to have hospital-specific data when you develop a plan,” she adds.

Analyze your data and your current readmission reduction efforts and determine where opportunities for improvement exist. Collaborate with providers across the continuum on ways to ensure smooth transitions, Boutwell adds.

Marshall recommends that hospitals adapt a team approach to improving transitions. The team should represent all the stakeholders in the readmission reduction process, including representatives from skilled nursing facilities, home health agencies, primary care providers, and families.

“The team has to understand what the problem is for that individual hospital, identify patients at risk, and develop a standardized process to educate patients and to hand them off to the next level of care,” she says.

Ask providers what kind of information they need for a successful handoff and how they want to receive it, adds Wanda Pell, MHA, BSN, a director with Novia Strategies, a national healthcare consulting firm.

“If the post-acute providers have the detailed information they need about the patients being transitioned to them and their post-acute treatment plan, they will be better prepared to provide the care the patients need to progress. Otherwise, if it looks like the patient is having problems and the provider’s staff doesn’t have complete information about the patient and the family members, they’ll send them to the emergency department every time,” she says.

That’s when it’s essential to have case managers in the ED who can deal with problems in the ED and possibly avoid a readmission, Pell says. (For details on how ED case managers can prevent readmissions, see related story in this issue.)

Hospitals and post-acute partners should use a uniform discharge education tool that can assess, educate, and re-educate patients on their diseases, discharge plan, and medication regimen. Hospitals should provide instructions on what to do if a problem arises, Marshall says. Working with post-acute providers to develop a tool that can be used throughout the continuum is essential, she says.