The Secret to Reducing Hospital Readmissions

Bright lights at the end the hospital corridor. The concept of life and death.

Reducing 30-day readmissions is at the top of many health systems “to-do” lists. As part of healthcare reform, the government will reimburse health systems who can successfully reduce 30-day readmission rates for patients. As the United States health system transitions from a fee-for-service model into an outcome-driven system, it has never been more important to identify all key factors–both in and outside of the hospital–that can help keep patients at home.

Access to community resources is a critically important factor in improving healthcare outcomes. A recent study published in Health Services Research shows that community demographics are primary drivers of reducing hospital readmissions– not necessarily the hospitals themselves. The study examined 4,073 hospitals in 2,254 counties over 3 years, and found that nearly 60% of the variation in hospital readmission rates appears to be associated with where the hospital is located– rather than on the hospital’s performance (1). Lead author of the study, Jeph Herrin, Ph.D, reflected on the results of the study, “The biggest surprise was how much affect the county or the community had on readmission rates.  Hospitals in the same area had similar readmission rates as others in the area.”

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This research recognizes the need for improved coordination and accessibility of community resources for people. Dr. Herrin also believes that hospital readmission rates should be addressed with community-based programs in addition to improvements within the hospital. Integrating more community resources into the patient care plan can have tremendous cost-savings for the hospitals. Simple community resources, such as having someone deliver healthy meals or help the patient with chores around the house can have a huge impact on readmissions. Patients without the ability to cook or go to the grocery store may heal slower or experience more complications in their recovery.

A different study published last year by the Journal of the American Medical Association showed that when hospitals coordinated with community-based efforts, rehospitalizations decreased by 5.7 percent (2). This study looked at 14 different communities around the US and found that community-based interventions significantly improved care compared to the control group who did not receive community-based interventions. These studies shed light on the need for health systems to design multi-faceted care plans for their patients. If health systems and community resources can coordinate care outside of the traditional clinical environment, this will ensure that care transitions happen seamlessly and efficiently. This will help reduce readmissions and improve health outcomes while also driving down costs. Mary Ellen Dalton, Ph.D, MBA, RN and president of the American Health Quality Association agrees, “Hospital readmissions are not just a hospital problem, or a patient problem. They are a community problem, and ensuring that all sectors of a community work together to make care transitions effective is vitally important,” (2).


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