Original Research

Reducing hospital readmissions through primary care practice transformation

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This study found that a “culture of continuity” using processes that strengthen outpatient-inpatient caregiver communication improves patient care.




Purpose To assess the impact of a multicomponent intervention on 30-day hospital readmissions in a group of primary care practices that undertook practice transformation, compared with rates in usual-care practices that admitted patients to the same hospital service.

Methods Four primary care clinics enhanced patient care coordination with care managers and inpatient care teams, and developed and used hospital readmission reports to monitor readmission rates. Patient readmissions to the hospital were analyzed over a 12-month period from May 2012 through April 2013, among patients who fell into 2 groups. Group 1 patients were those cared for by the primary care clinics that implemented transformation activities and who were admitted to the hospital associated with the practices. Group 2 patients were seen at clinics in the same catchment area that did not undertake any known practice redesign activities (usual care group).

Results A total of 961 patients were included in analyses; 685 (71.3%) were in Group 1, and 276 (28.7%) were in Group 2. Readmissions among Group 1 patients decreased from 27% to 7.1% (P=.02), and readmissions in Group 2 were variable with a nonsignificant trend (P=.53). The unadjusted regression model that compared the interaction between Group 1 and Group 2 patients found a significant difference in readmissions (P=.05).

Conclusion Developing a multicomponent intervention appears to have a significant impact on reducing hospital readmissions. Primary care groups seeking to reduce hospital readmissions should consider implementing similar processes.

An analysis of Medicare claims data between 2003 and 2004 found that nearly 20% of the >11 million Medicare patients who had been discharged from a hospital were readmitted within 30 days, at a cost of $17.4 billion.1 Certain patient subgroups were especially worrisome. Of those with congestive heart failure, for example, 50% were typically readmitted within 6 months of initial hospitalization.2

A longstanding issue comes to the fore. Concerns about hospital readmissions appeared in the literature nearly 40 years ago.3 In the 1990s, with the advent of managed care, organizations began “case management” to reduce preventable readmissions using several approaches, including enhanced primary care access.4 A meta-analysis at that time demonstrated some reduction in hospital readmissions associated with hospital-based case management interventions.5 Though quality improvement programs and case management have been assumed to reduce hospital readmissions, some studies have actually found the opposite,6,7 or have yielded conflicting evidence.8-13 Skyrocketing costs of health care have brought hospital readmissions to the forefront of health system redesign efforts.14-16

Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires Centers for Medicare & Medicaid Services to reduce payments to hospitals with excess readmissions.17 This change was introduced on October 1, 2012 and has precipitated discussion across the country about the prevention of unnecessary hospital readmissions.18,19

Compared with usual care, this multicomponent intervention more successfully reduced readmissions. Patient factors contributing to hospital readmissions. Concerns patients cite most frequently as contributors to relapse and readmission are 1) feeling unprepared for discharge; 2) difficulty performing activities of daily living; 3) trouble adhering to discharge medications; 4) difficulty accessing discharge medications; and 5) lack of social support.20 While multiple tools have been developed to better assess unplanned readmissions—including the Identification of Seniors at Risk, the Flemish version of the Triage Risk Screening Tool, and Variable Indicative of Placement risk—none of these have accurately predicted unplanned readmission in older, hospitalized patients.21 Predicting which patients will require readmission remains elusive,22 though some new models show promise.23 z

Targeted interventions that show promise. Postdischarge telephone follow-up has been shown to reduce hospital readmissions,24,25 and a direct correlation has been observed between the timing of the intervention and readmission rates, with interventions implemented closer to the date of discharge being associated with greater reductions in the number of readmissions.26 Additionally, multicomponent interventions with both pre- and postdischarge elements that specifically target high-risk populations appear to be more effective in reducing readmissions than single-component interventions.27

Hansen et al28 identified a number of predischarge, postdischarge, and bridging interventions that could potentially reduce hospital readmissions (TABLE 1). No single intervention implemented alone consistently reduced the risk for 30-day rehospitalization.28 One multicomponent intervention that has reduced readmissions for patients with heart failure or acute myocardial infarction is a transition coach, who visits patients in the hospital and sees them again in clinic for follow-up appointments. The coach also calls patients between face-to-face visits to review treatment plans and answer questions.29

The impetus for our study. The patient-centered medical home (PCMH) has been gaining traction as a mechanism to improve patient care while reducing health care spending.30,31 An intensive multidimensional medical home model introduced into 11 primary care practices proved capable of significantly reducing admissions and readmissions for Medicare Advantage members.32 Additionally, intelligently leveraging clinical information technology is likely to be critical in reducing readmissions.33 The purpose of our observational study was to examine the impact of a multicomponent intervention on 30-day hospital readmissions over 12 months.


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