Build a three-part readmission prevention strategy

Topics: Readmissions, Quality, Performance Improvement, Nursing

August 11, 2011

While clinical leaders have an ongoing interest in reducing readmissions to improve care quality, economic forces have recently pushed readmissions into the national spotlight. There is now widespread consensus among policymakers and industry leaders that the nation’s health care system can save billions of dollars by preventing avoidable readmissions.

The Nursing Executive Center’s latest publication, Nurse-Led Strategies for Preventing Avoidable Readmissions: Coordinating Care for Complex Patients Across the Continuum, identifies three components of an executive-level readmissions prevention strategy:

  • Expand beyond a disease-specific approach
  • Collect actionable data on potentially preventable readmissions
  • Strengthen care coordination across the continuum

Expand beyond a disease-specific approach
Currently, most hospital leaders focus their readmission prevention efforts on all patients with a certain condition, such as heart failure (HF) or pneumonia. However, re-hospitalizations from those two conditions only account for about 16% of the annual total. Even if a disease-specific approach targets the four most frequently re-hospitalized conditions, it only addresses patients with conditions accounting for approximately 24% of readmissions.

Put simply, a disease-specific approach is unlikely to impact the majority of patients at risk for re-hospitalization. To ensure readmission prevention efforts have the greatest possible impact, hospital leaders should broaden their focus to all patients at risk for readmission—regardless of condition.

Collect actionable data on potentially preventable readmissions
Admittedly, not all readmissions are preventable. The following table plots sample readmissions based on whether the readmission was planned (or not) and related to the initial hospitalization (or not). To ensure limited resources are used as efficiently as possible, readmission prevention efforts should focus on readmissions that are both unplanned and related.

Moreover, hospital leaders must collect data to determine which of their institution’s admissions are potentially preventable. Fortunately, most organizations do not need to collect additional data in order to accomplish this objective. Rather, many hospitals simply need to filter existing data using one of several published methodologies.

Strengthen care coordination across the continuum
The third and most challenging component of the Center’s three-part strategy is to strengthen coordination across the entire continuum of care. The goal is to ensure patients receive appropriate care at all points in the continuum and do not require re-hospitalization due to a lapse in care post-discharge. According to data from the Joint Commission and Heart Failure Registry databases, as many as 80% of heart failure patients discharged from a hospital setting receive incomplete discharge instructions or no instructions at all. Additional examples of gaps in care that can lead to readmissions are illustrated below.

Given this formidable challenge, the Nursing Executive Center’s latest publication identifies 14 best practices for strengthening coordination across the continuum, including methods to leverage the inpatient stay to equip patients for long-term self-management and facilitate seamless transfers to post-acute care settings.

For more information
Download or order unlimited copies of the Center’s latest study, Nurse-Led Strategies for Preventing Avoidable Readmissions. Daily Briefing readers with questions about the Nursing Executive Center may email