Preventing readmissions benefits patients, saves money

Good communication, follow-up calls are key

In a concerted effort to improve patient care, payers and providers are collaborating to improve transitions of care and reduce readmissions.

A study in the New England Journal of Medicine1 showed that one-fifth (19.6%) of Medicare beneficiaries were rehospitalized within 30 days of discharge, at a cost of $17.4 billion. The study concluded that the average stay of rehospitalized patients was 0.6 days longer than patients in the same diagnosis-related group whose most recent hospitalization had been at least six months prior.

"It's clear that keeping patients from being readmitted benefits the patient and saves the healthcare system money as well. When you add 0.6 days onto the typical diagnosis, it adds up to a lot of money. In addition, hospitalization can expose patients to infections and put them at the risk for falls," says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, consulting firm specializing in hospital case management.

Reasons for avoidable readmissions include poor or inadequate discharge plan, discharging the patient too soon, no plan for follow up care, medication compliance issues, and the patient's failure to see a primary care physician for follow-up within a week after discharge, according to Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts, LLC.

"When people are readmitted within 30 days, it means that somewhere the system has failed. Either the patient didn't get appropriate ambulatory or inpatient care, they didn't receive care at the appropriate level of care at the most appropriate time, or there were problems with the transition of care," says Tracy Langlais, RN, vice president of medical affairs operations for Capital District Physicians Health Plan (CDPHP), based in Albany, NY.

Since studies have shown that one cause of readmissions is lack of follow-up care, case managers should make sure that patients have an appointment to see their doctor for follow up within seven days of discharge and should make sure they understand the importance of keeping the appointment, Cesta says.

Make a follow-up phone call shortly after discharge to make sure the patient is taking his or her medication, has a doctor's appointment, and is not having problems, she says.

Following up after discharge helps the case managers identify issues that could mean problems down the road for patients, says Mary Hickie, RN, case management services director for Blue Cross Blue Shield of Arizona Advantage. The health plan makes follow-up calls and home visits after discharge to patients who qualify for case management.

"Patients are given so much information at discharge that they often don't remember everything. The case managers have access to the electronic medical records at Banner Health facilities and can review the discharge instructions to make sure the patient understands them. They get information about the medication prescribed and can conduct medication reconciliation over the telephone," she says.

In one instance, when a case manager made a follow-up call the day after discharge, the patient didn't remember getting two prescriptions, one of which was for an antibiotic. The case manager asked the patient to check the bag he received at discharge and he found the prescriptions. When she called back the next day, the patient reported getting his prescriptions filled and taking them as instructed.

If the patient hadn't found the prescriptions, the next step was for the case manager to visit the home the next day and go over all the paperwork with the patient.

Communicating with the patient and family before and after discharge is an important part of reducing readmissions, but don't overwhelm them, Kizziar says.

"When patients leave the hospital, they sometimes get follow-up calls in a matter of days from the hospital, their health plan, their doctor, and in some cases, someone doing a patient satisfaction survey. It is overwhelming and confusing and may annoy patients and family members to the point that the calls are ineffective and it certainly doesn't speak well for the healthcare industry," she says.

She advises case managers making follow-up calls to ask open-ended questions rather than those that can easily be answered "yes." Ask them to tell you what medications they are taking and when they are taking them. Instead of asking heart failure patients if they are weighing themselves daily, say "tell me your morning routine."

Payers and providers need to work together to coordinate phone calls and improve transitions, Kizziar says.

Capital District Physicians Health Plan partners with physicians to ensure that patients receive follow-up appointments and provides in-home case management for frail elderly members at highest risk. In addition, case managers call at-risk patients at regular intervals for 30 days after discharge and provide daily discharge reports to physicians.

"Everybody in health care is trying to reduce readmissions, but those who are the most successful are those that are collaborating with other organizations. When the payer, the hospital, and the primary care provider come together, they are able to make a program happen," she says.


  1. NEngl J Med April 2, 2009:360:1481-28