Strategies to help reduce hospital readmissions

Foster communication between
 the hospital and outpatient office

Patients are particularly vulnerable during the transition from hospital to home. Delayed or inaccurate information adversely affects continuity of care, patient safety and satisfaction, and efficient use of resources.¹² Discharge summaries are the main method of communication between providers, but their content, timeliness, availability, and quality frequently are lacking.¹³ Discharge summaries are available at only 12% to 34% of first postdischarge visits, and these summaries often lack important information such as diagnostic test results (33%-63%) or discharge medications (2%-40%).¹² Although researchers have not consistently found that transferring a discharge summary to an outpatient physician reduces readmission rates, it is likely that direct communication can improve the handoff process independent of its effects on readmissions.^12,14

Timely follow-up appointments
 are essential


Many factors influence the need for rapid follow-up, including disease severity, management complexity, ability of the patient to provide sufficient self-care, and adequacy of social supports.^15,16 Studies have found that discharged patients who receive timely outpatient follow-up are less likely to be readmitted.^1,17 While the optimal time interval between discharge and the first follow-up appointment is unknown, some literature supports follow-up within 4 weeks.^15,18 However, because readmissions often cluster in the first several days or week following discharge,¹⁸ follow-up within the first 2 weeks (and within the first week for higher-risk patients) may be appropriate.¹⁹ Ideally, follow-up appointments should be scheduled before the patient is discharged. Patients who schedule a follow-up appointment before they are discharged are more likely to make their follow-up visit than those who are asked to call after discharge and schedule their own appointment.¹²

Set up a follow-up appointment within one or
 2 weeks of discharge, depending upon the patient’s risk of readmission.Employ outpatient 
follow-up alternatives

Follow-up telephone calls to patients after discharge help patients understand and adhere to discharge instructions and troubleshoot problems. Clinicians who use scripted telephone calls can evaluate symptoms related to the index hospitalization, provide patient education, schedule relevant appointments or testing, and, most importantly, initiate medication reconciliation, which is described at right.²⁰ The FIGURE includes the script we use at our practice.

Home visits may be appropriate for certain patients, including the frail elderly. Home visits allow clinicians to evaluate the patient’s environmental safety, social sup port, and medication adherence.¹² Preventive home visits generally have not been found to reduce hospital readmissions, but do enhance patient satisfaction with care.²¹

Bundled interventions, such as alternating home visits and follow-up telephone calls, may be more effective than individual interventions in reducing readmission.²²

Reconciling medications may have far-reaching benefits


Medication discrepancies are observed in up to 70% of all patients at admission or discharge and are associated with adverse drug events (ADEs).²³ To prevent ADEs and possibly readmission, take the following steps to reconcile a patient’s medications²³:

Obtain a complete list of current medications. Information on all of the patient’s prescription and nonprescription medications should be collected from the patient/caregiver, the discharge summary, prescription bottles, home visits, and pharmacies.^12,24

Reconcile preadmission and postdischarge medications. Clarify any discrepancies, review all medications for safety and appropriateness, and, when appropriate, resume any held medications and/or discontinue unnecessary ones.

Research shows that patients who received a phone call from a pharmacist within 3 to 7 days of discharge had lower readmission rates.Enlist pharmacy support. Pharmacists are uniquely positioned to review indications as well as potential duplication and interactions of a patient’s medications. Inpatient studies have demonstrated that partnering with pharmacists results in fewer ADEs.12,25 One study showed that patients at high risk for readmission who received a phone call from a pharmacist 3 to 7 days after discharge had lower readmission rates.26 The pharmacist reconciled the patients’ medications and ensured that patients had a clear understanding of each medication, its common safety concerns, and how often they were supposed to take it.26

Make medication adherence
 as easy as possible


As many as half of all patients don’t take their medications as prescribed.²⁷ There is limited data on health outcomes associated with medication nonadherence, and existing data frequently are contradictory—some studies have found that as many as 11% of hospital admissions are attributed to nonadherence, while others show no association.²⁸

A patient who understands the purpose of a recommendation—especially when directly linked to a patient-derived goal—may be more likely to adhere to a plan of care.Factors that affect adherence include psychiatric or cognitive impairment, limited insight into disease process or lack of belief in benefit of treatment, medication cost or adverse effect profile, poor provider-patient relationship, limited access to care or medication, or complexity of treatment.²⁹ To promote medication adherence, consider the following educational and behavioral strategies³⁰: