Reducing Preventable Readmissions

Elevating Transitions and Disease Management to Perfect Care Across the Continuum

This study details eight imperatives for reducing preventable cardiovascular rehospitalizations through discharge planning, transitional and post-acute care, and disease management.

Executive Summary

Federal scrutiny over the cost and inefficiencies of the health care system has placed a spotlight on readmissions. As uncovered in MedPAC’s report to Congress, 18 percent of patients are readmitted within 30 days costing the government $15 billion. Of the top seven conditions readmitted in 15 days, five are CV in nature, comprising nearly one-fifth of the total cost of readmissions.

Furthermore, public reporting of all-cause 30-day heart failure, AMI, and pneumonia readmissions measures underscores the urgency to reduce re-hospitalizations. State-specific variation in readmission rates suggests there is substantial room to improve, and upon closer inspection, over three-quarters of 30-day all-cause readmissions are deemed preventable.

While certain predictors of readmissions (i.e., hospital attributes, patient characteristics, and clinical conditions) may be beyond the CV department’s control, programs may inflect change by improving hospital processes, namely enhancing the discharge process, streamlining the transition out of the hospital, and augmenting care delivered after discharge.

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