Don’t just get them out—Make sure they stay out

Pay attention to post-discharge care

In the past, case managers and discharge planners have concentrated on how to get patients out of the hospital, but now they also need to focus on how to keep them from coming back, says Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, a healthcare consulting firm based in Shawnee, OK.

“Case managers play a major role in helping avoid readmissions. As they perform discharge planning, they should make sure the patients receive appropriate education on what to do after discharge so they don’t come back because they didn’t understand their instructions. They will need to be creative in order to find resources for patients who can’t afford their medications so they won’t come back because they didn’t get their prescriptions filled,” she says.

Readmissions can affect a hospital from a financial perspective and may have negative connotations from a patient safety perspective. That’s why CMS is putting so much emphasis on readmissions, says Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newton Square, PA-based physician advisor company.

“It is difficult to give blanket guidance on readmissions because the patient population and processes differ among hospitals. We know hospitals should focus on heart failure, acute myocardial infarction, and pneumonia because those are the ones that CMS is looking at. But keep in mind that CMS is going to add more diagnoses in the future,” Wuebker says.

He advises case managers to determine which diagnoses are at high risk for readmission and concentrate on improving care within the hospital and smoothing transitions in those areas.

Don’t just concentrate on diagnoses that CMS is focusing on, advises Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago. Analyze the data in your hospital’s Program for Evaluating Payment Patterns Electronic Report (PEPPER) and see how you compare to other facilities to get a sense of where your opportunities for improvement are found, Sallee suggests.

Start by making sure that a way to identify readmitted patients is built into the computer system, she says. Analyze every readmission and determine what brought the patients back. Look at what you are doing now, what areas need improvement, and what resources you will need to improve the process.

It could be something as simple as discharge instructions, Wuebker says. He tells of one hospital that reviewed readmissions and found that the 15-page packet of instructions patients received at discharge was overwhelming to the extent that the patients did not even try to read it. They distilled the information into a one-page document with the key items patients needed to know.

Medication reconciliation is another big area that can affect readmissions, Wuebker says. “If patients don’t take the right medications as prescribed, they are likely to get in trouble at home. It’s not good enough just to hand them a prescription. Someone also needs to make sure they got it filled,” he says.

Teresa Treiger, RN-BC, MA, CHCQM-CM/TOC, CCM, president of Ascent Care Management, LLC, a case management consulting firm based in Holbrook, MA, tells of a client with heart failure who was taking a generic brand of a diuretic at home and was discharged with a prescription for a name brand of the same medication. The patient took both and ended up back in the hospital.

When patients are taking multiple medications, get the hospital pharmacist involved to review the medications prescribed in the hospital as well as those the patient was taking before admission. Make sure the patients and caregivers understand the medications, including why and how they should take them, she adds.

Sallee offers more tips for preventing readmissions:

  • Don’t just collect data. Make sure there is a way to turn data into information that can be used to make improvements, Sallee says.
  • Look for patterns in readmissions, such as whether a significant number are coming from a particular post-acute provider, then work with them to identify and remedy the problems.
  • Go beyond educating patients on what they need to do to manage their condition and make sure they have the ability to do it. Identify patient vulnerabilities that may have been overlooked. For instance, patients may come back because they couldn’t afford their medication, they could be instructed to weigh themselves but they don’t have scales, or they may not go to their follow-up appointment because they don’t have transportation.
  • Use multidisciplinary rounds as an opportunity to look for at-risk patients, identify trends and make changes.
  • Don’t try to re-invent the wheel, Sallee says. Join with other hospitals and find out what worked for them.


  • Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, Shawnee, OK. email:
  • Linda Sallee, MS, RN, CMAC, ACM, IQCI, Director, Huron Healthcare with headquarters, Chicago. email:
  • Teresa Treiger, RN-BC, MA, CHCQM-CM/TOC, CCM, president, Ascent Care Management, LLC, Holbrook, MA,
  • Ralph Wuebker, MD, MBA, Chief Medical Officer, Executive Health Resources, Newton Square, PA. email: