The Discharge Process Role in 30-Day Readmission Reduction

Simple communication is central to successful reductions of readmissions. By the time of discharge, the patient must be aware of what is happening. They should know when they are leaving, and have any issues related to their transportation and ongoing care addressed in advance. Simply meeting these needs has been shown to improve outcomes, and of course, reduce 30-day readmission rates [35].

Key considerations for any successful program will be:

Disease education. This is usually a cross-functional effort, aimed at ensuring every patient fully understands their healthcare requirements and understands their own role in their recovery or management. A newly diagnosed diabetic without insurance or a PCP will need education, medication, dietary instruction, and a follow-up Physician, for example. This patient will need input from nursing, physician, social work, pharmacy, and a diabetic teacher. Whether the patient smokes or drinks will also be a factor, potentially adding further to the educational component.

Medication education. Incredibly, this is often neglected. Often, patients are sent home with little understanding of the medication they have been prescribed—and can end up right back in the ED as a result. While medication reconciliation may occur, hospitals often fail to go further. Patients need to understand what they are taking a medication for, the consequences of not taking it, what side effects to look out for, interactions with other medications including over the counter and herbal medicines and what to do if you are going to run out of your medicines.

Follow-Up Plans

Before discharge, the hospital should ensure each patient has a solid plan for follow-up with a physician. Appointments need to be made and any transportation issues resolved. Home care or other ancillary needs have to be addressed. Sub-specialty follow-up can be a significant issue for patients without a PCP and should be addressed before discharge. Most 30-day readmissions (50%) actually occur in the first 2 weeks following discharge and are often related to lack of follow-up. High-risk patients should be provided follow-up appointments within 48-72 h following discharge from the acute care facility. As discussed earlier, when we surveyed PCPs about follow-up appointments for their patients following a hospitalization, the majority of time the patient was added onto the doctor’s already busy schedule resulting in a 10- or 15-min visit. Patients with complex diseases, multiple medications, and extended stays in the hospital will usually require a much longer appointment visit to make sure all the patients’ issues are addressed.

Hand-off. Physician to physician hand-offs, or Provider to Provider if PAs or NPs are utilized ensure that further care needs will be met at the time of discharge. This provides the follow-up provider with information on the patient’s diagnosis, treatment rendered, testing completed, sub-specialty consultation obtained and any other outstanding issues such as need for medication adjustment, changes in medications or dosages, and need for further testing and/or consultation.

Addressing these issues at discharge will result in all members of the patient’s healthcare team, both hospital-based and non-hospital-based, to be on the same page in understanding what the needs of the patient will be, and ensure the patients themselves understand their own condition and care needs. Communication at this level has become vital as our healthcare delivery system has grown ever more fragmented. Hospitals that educate patients and coordinate with PCPs will certainly see fewer of their patients return within 30 days. If, however, the PCP is unaware of the patient’s current hospitalization, care rendered, medication changes, referral to an alternative care facility, sub-specialty consultation, testing or use of home care, then a very high rate of 30-day readmissions is inevitable.

Certain specialty surgical procedures have been shown to have a high rate of 30-day readmissions. In particular, post- CABG, post-Vascular, and post-Colorectal surgeries experience readmission problems. Why is this? Because of lack of followup and communication with PCPs. Often, secondary issues that could have been foreseen or adverted with proper communication and follow-up cause readmissions—and patients are rarely admitted to the surgical service they were discharged from. Instead they flow back to the ED. Many of these patients have medical issues that the PCP is skilled at managing. These medical issues can become complicated in surgical patients that have diabetes, heart disease or multiple other medical disorders.

A typical example of this phenomenon, which was discussed earlier, would be a post-CABG patient experiencing chest pain or palpitations, developing a fever or UTI or have some other condition which may be linked to the surgery itself. Timely follow-up with that patient’s PCP before initial discharge would likely result in a standard post-CABG protocol, including items such as EKG, U/A, physical exam, and education, all of which would reduce the chances significantly of a readmission—while improving the chances of a positive outcome for the patient.

Models for facilitating this level of communication and follow-up will vary, but should include hard hand offs, followup appointments and education. Any hospital interested in reducing readmissions (and caring for patients) must address this need.

The Post Discharge Role in 30-Day Readmission Reductions

Patients are discharged to a variety of settings when leaving acute care:

• (1) Nursing home
• (2) Skilled rehab
• (3) Alternate facility-(Psych), group home, prison
• (4) Shelter
• (5) Home
• (6) Hospice

Discharged patients are also referred to a variety of providers. Some common referrals are:

• (1) Home care
• (2) Physical therapy
• (3) Respiratory therapy

• (4) Diabetic teaching
• (5) Home visit provider-physician or APP

Regardless of what facility or provider is involved, the PCP needs to be aware of where their patient is and who is caring for them. The importance of this cannot be understated. Many patients return to the ED because of a lack of communication with the PCP at discharge and when a referral occurs. Often, a home care visit results in a readmission, with no communication with or direction from a poorly informed and unaware PCP. Without the opportunity to properly care for this patient, the PCP is rendered useless and the patient’s chance for a positive outcome is diminished.

There is no doubt that 30-day readmission reductions can have a significant impact on hospital capacity management, as well as on hospital finances. We recommend that hospitals develop broadly represented 30-day readmission reduction committees. While a challenge to administer, this area of healthcare will only become more important in years to come, as the transition of care to the outpatient arena becomes more prominent and as CMS continues to increase penalties for high readmissions rates. Healthcare organizations that develop quality discharge policies now will reap rewards well into the future and will provide better quality and lower cost care for their patients.