Reduce Readmissions By Automating Post-Discharge Care

In the U.S., hospital readmissions are a major problem that cost Medicare about $17B annually with other payers spending roughly the same amount. Between 50% and 75% of these readmissions are considered to be preventable. The immediate cause of a readmission is usually a rapid deterioration in the patient's condition, related to the patient's primary diagnosis and/or comorbidities. But in a broader sense, it can be attributed to systemic failures that begin in the hospital and continue in the fragmented health care settings that patients move through after discharge.

Until recently, some hospitals took the attitude that their responsibility for care ended when the patient walked (or was wheeled) out the door. Other facilities have used a variety of techniques to reduce readmissions, with mixed results. But new government incentives, plus a rising awareness of the need to improve patient safety, are forcing hospitals to place an increased emphasis on discharge planning and post-acute care.

A great deal of research has been done on the best methods for reducing readmissions. In this section, we will focus on the Institute for Healthcare Improvement's (IHI's) recommendations; the Coleman Care Transitions Intervention; and the Naylor Transitional Care Model. Other resources for healthcare organizations include the BOOST program of the Society of Hospital Medicine;20 the Care Transitions Performance Measurement Set of the Physician Consortium for Performance Improvement;21 and the Transitions of Care Consensus Policy Statement of the American College of Physicians and five other specialty societies.

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