Readmissions

Readmissions Summary:

 What Are They?

"Readmission" occurs when patients who have had a recent stay in the hospital go back into a hospital again. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason. Often referred to as "rehospitalization."

Who's At Risk?

Patients in transition - those moving from one care setting to another - are at increased risk for hospital readmission.  Unanswered questions including  the following, can increase patient risk for readmission: who is in charge of the patient transition, what is the plan, whether the plan and follow-up instructions are understood, and knowledge of whom to call with questions once they are home or in their new care setting.

What's At Stake?

Patients move from one setting of care to another or to one set of care providers to another during an episode of illness. As patients and families navigate across new care settings and among different care providers, they often encounter communication challenges and confusion around who is clearly accountable for their care. This can lead to medical errors, duplication, increased costs and may also lead to higher rates of hospitalization.

What Providers Are Doing to Prevent Readmissions?

Massachusetts is currently participating in many projects to address and improve hospital readmission issues.  These efforts are largely coordinated state-wide by the Massachusetts Care Transitions Forum, and a list of these projects follows.

• Re-Engineered Discharge (RED) Toolkit from AHRQ
• Potentially Preventable Readmissions (PPR) Project with 3-M
• STAAR Initiative:  STate Action on Avoidable Rehospitalizations
• Interventions to Reduce Acute Care Transfers (INTERACT-II) Initiative
• MOLST Demonstration Project:  Medical Orders for Life-Sustaining Treatment
• Project RED (Re-Engineered Discharge)
• Project BOOST (Better Outcomes for Older Adults through Safe Transitions)
• Home Care Projects:  Masspro Collaborative Project
• Business-led Projects:  Dovetail Health's pharmacist-led Transition Services to Avoid Costly Readmissions

Hospital Guide to Reducing Medicaid Readmissions

A guide to help acute care facilities expand their current Medicaid readmission efforts is now available from AHRQ.

The new resource, titled Hospital Guide to Reducing Medicaid Readmissions, can help acute care facilities accomplish the following:

• Adopt or expand existing Medicaid readmission reduction efforts. It helps identify readmission risks, transitional care needs, and adopt best practices from proven strategies like AHRQ's Re-Engineered Discharge, the Institute for Healthcare Improvement's State Action on Avoidable Readmissions, and the Society of Hospital Medicine's Better Outcomes for Older Adults Safe Transitions to serve the transitional care requirements of Medicaid patients.
• Develop your Medicaid reduction strategy using the guide's roadmap featuring 13 customizable online tools. The tools can be downloaded individually here.
  Comply with CMS' Conditions of Participation requirements for a standard, improved, and transitional care for all patients. National, state, and local data show high rates of non-obstetric Medicaid readmissions.
• Develop partnerships across other settings of the healthcare continuum. The tool helps create an inventory of resources and processes to aid in building multidisciplinary teams with organizations and facilities offering post-hospital Medicaid transitional services.

The guide is the only federal tool available tailored to the adult Medicaid population. Hospitals at different stages of readmission reduction work can benefit from implementing this guide.