Hospital readmissions are a common problem that adds to the cost of healthcare and puts patients at risk for further complications.

According to a study by the Agency for Healthcare Research and Quality, nearly 20% of Medicare patients are readmitted to the hospital within 30 days of initial discharge, and half of these readmissions are avoidable. Breaking the cycle of hospital readmissions requires a multidisciplinary approach that addresses the underlying causes and provides appropriate interventions.

Risk Factors for Hospital Readmissions

Several factors contribute to a patient’s risk for hospital readmission. These include age, chronic diseases, poor nutrition, medication nonadherence, and lack of social support.

Patients with multiple chronic conditions are at a higher risk for readmission, particularly if they have inadequate follow-up care or are discharged too soon. Older adults are also at a higher risk for readmission due to their decreased ability to recover and adjust to changing health status.

Improving Care Transitions

One critical way to reduce hospital readmissions is to improve the process of care transitions from hospital to home or other care settings.

Better communication between healthcare providers and patients can help ensure that patients understand their discharge instructions and are aware of their medications, follow-up appointments, and self-care responsibilities. Providing patients with a written discharge plan and follow-up phone calls or visits can also reduce the risk of readmission.

Medication Management

Another significant contributor to hospital readmissions is medication nonadherence or errors.

Factors such as low health literacy, polypharmacy, and complex medication regimens can make it challenging for patients to manage their medications effectively. Healthcare providers can reduce this risk by emphasizing the importance of medication adherence, simplifying medication regimens, and providing patients with educational materials and counseling on their medications.

Implementing medication reconciliation procedures during care transitions can also ensure that patients receive accurate and appropriate medications when leaving the hospital.

Chronic Disease Management

Patients with chronic diseases such as heart failure, chronic obstructive pulmonary disease (COPD), and diabetes are at a higher risk for hospital readmission.

Effective disease management may include patient education, lifestyle modifications, medication adjustments, and close monitoring by healthcare providers. Patients should understand the warning signs of exacerbations and know what to do if they experience them.

Healthcare providers can help manage chronic diseases by providing patients with individualized care plans and self-management tools such as telehealth services or mobile applications.

Home Health Services

Home health services such as skilled nursing, physical therapy, and home health aides can help facilitate a patient’s recovery and prevent readmissions.

These services may include wound care, medication management, and rehabilitation after surgery or injury. Home health services can also provide patients with social support and help address barriers to self-care such as transportation or financial concerns.

Follow-Up Appointments

Following up with patients after hospital discharge can help identify problems early and prevent readmissions.

Providers may schedule follow-up appointments with primary care physicians or other specialists to assess a patient’s recovery and adjust treatment plans as needed. Follow-up appointments can also provide an opportunity to address medication concerns and provide patient education and support.

Community-Based Services and Resources

The availability of community-based services and resources can impact a patient’s recovery and prevent readmissions.

Resources such as meal delivery, transportation assistance, and financial aid can help address social determinants of health that may impact a patient’s ability to access care and manage their health. Partnerships with community organizations and agencies can help ensure that patients have access to these resources and can help providers identify and address social determinants of health that may be contributing to readmissions.

Patient and Family Engagement

Patients and their families play a critical role in preventing hospital readmissions.

Patients who are engaged in their care and feel supported by their families are more likely to follow through with their treatment plans and take an active role in their recovery. Providers can encourage patient and family engagement by involving them in care planning, providing education and resources, and addressing their concerns and questions.

Conclusion

Hospital readmissions are a significant problem that can be addressed through a collaborative and multidisciplinary approach.

By improving care transitions, medication management, chronic disease management, providing home health services, scheduling follow-up appointments, and engaging patients and families in care, healthcare providers can reduce the risk of readmission and improve patient outcomes.