OpenPlacement Blog

Understanding and Improving Discharge: A Critical Factor in Reducing Potential For Readmission

Introduction.  Recent studies have shown that the discharge process can be very difficult.  The challenges of the complex process can easily lead to errors that lead to unnecessary re-hospitalization.  Preventing these both improves the patient's outlook and prevents care facilities from receiving penalties associated with excessive readmissions.  This report takes a look at the discharge process and some of the data gathered over the last several years as a means of understanding and improving discharge.

The importance of effective discharge planning.  Studies from the Agency for Healthcare Research and Quality demonstrated that there were more than 39 million discharges in the United States in 1996.  Unplanned re-hospitalizations cost a whopping 17 and a half billion dollars, accounting for nearly a fifth of Medicare's hospital payments between 2003 and 2004.  The end result, according to the Centers for Medicare and Medicaid Services' Readmissions Reduction Program, is that in 2012, about two out of every three facilities received some sort of penalty for excessive readmissions.

What does this mean for discharge planners?  Simply put, effective discharge planning can play a role in reducing readmissions.  The National Institutes of Health found in 2012 that patients with discharge planning were more satisfied than those without, and enjoyed decreases in both length of stay and readmissions.  Medication verification of patient medicine lists by discharge planners effectively reduced the number of actual and potential adverse drug effects to patients.  Finally, discharge information, such as the discharge summary and checklist, was studied as a critical part of avoiding readmission (although studies have found unfortunately that communication deficits often negatively affect the continuity of patient care).

Mitigating factors.  In spite of the importance of effective discharge planning, it's a fact that many readmissions are unavoidable.  To highlight the fact, a study of Medicare data for more than 200,000 heart failure and pneumonia patients showed that initial admission rates for such conditions in individuals with similar conditions correlated very strongly with re-hospitalization rates - contributing to readmission far more than other factors such as the size of the facility or effective discharge planning practices.  The research at this point as to the number of preventable re-hospitalizations is somewhat lacking, to the effect that studies were unable to define the term "preventable" or agree on the range of reported rates.  In frank terms, the data is extremely subjective.  However, clinician and system-level issues like inadequate post-discharge support, therapeutic errors, medication related issues, and failed handoffs are thought to be likely culprits.

Success in effective discharge planning.  Nevertheless, efforts to revamp the discharge and post-discharge process as a means of hopefully curbing re-hospitalization are ongoing.  A systematic review from the Northwestern University Feinberg School of Medicine has attempted to understand the effectiveness of various aspects of the discharge process by categorizing and evaluating discharge in areas such as pre-discharge interventions like patient education and medication review, post-discharge interventions (that include follow up calls and home visits, bridging interventions by using transition coaches, and physician continuity.  The same study found that eighty percent of the successful studies in terms of curbing re-hospitalization rates involved simultaneous practices related to the discharge process, including the provision of patient-centered discharge instructions and post-discharge telephone communication.

Research conducted in 2012 found further evidence that effective discharge and post-discharge care is critical to patient well-being.  Medication review, discharge summaries, proactive discharge planning, and effective communication between care providers all positively affected re-hospitalization rates, care continuity, and patient satisfaction.  Because every case is different and depends on a variety of factors, the study concluded it was unclear which specific practices had the greatest impact.  One of the conclusions the study made clear was among the most important was that multifaceted post-discharge interventions were by far the most successful, suggesting the need for an approach that combines a variety of post-discharge care strategies.

The multidisciplinary approach to discharge planning.  Reviews of several of these strategies have been conducted, while others are ongoing.  Telephone calls, home visits, and telemonitoring were three initiatives that have yielded interesting data following research.  For example, it was determined in a study by the Department of Clinical Pharmacy's School of Pharmacy at the University of California, San Francisco that telephone calls reduced emergency department visits, and noted a single study that suggested phone calls reduced re-admission rates.  A separate study sponsored by the Cambridge Health Alliance determined that phone calls improved follow-up with ambulatory providers.  A 1998 bit of research from the Queen Elizabeth Hospital and University in Australia determined that home visits could possibly cut readmission rates in half.  Telemonitoring, suggested a study conducted in 2001, resulted in a trend toward fewer re-hospitalizations and reduced care costs.

Given the data, multiple interventions in the discharge and post-discharge process go a long way in improving the patient's overall health as well as their rates of readmission.  A study conducted by the Boston University School of Medicine sought to evaluate the multidisciplinary effort that included several types of intervention, such as

  • A discharge advocate who was included to assist with preparation and discharge planning.

  • Telephone communication from a clinical pharmacist between two and four days after discharge.  This individual was tasked with reviewing medications, addressing any concerns, reviewing the plan with the patient, and attempting to evaluate any potential side-effects from the medications.

  • Appointments for follow-ups, which were scheduled in advance.

  • Medical review.

  • An easy to read literacy discharge instruction book for discharged patients.  This booklet would also be provided to the patient's primary care physician for reference.

  • It may not come as much of a surprise that the evaluation concluded the following: "A package of discharge services reduced hospital utilization within 30 days of discharge."

Discharge_2Conclusions.  What does all of this research mean?  While data continues to be compiled and further research continues to improve the discharge process, several important conclusions can be drawn from the data.  The first is that there are multiple factors that may result in re-hospitalization, and the discharge decision requires the evaluation of those factors.  It is important to remember that the discharge process itself cannot be blamed for all - or even most - of readmission.  Research has not reached the point where it is clear which instruments for determining the appropriateness of patient discharge can be truly validated.

That having been established, the research is clear that discharge planning is a critical factor in ensuring the patient's continued health and reducing the potential for readmission.  This process must necessarily include a multifaceted approach that requires the caregiver, the patient, the patient's family, and the discharge planner to work as a team.  For this process to succeed, it should include medicine reconciliation, a plan for patient follow up, and a thorough and detailed discharge summary that is provided for and explained to all parties involved in the patient's care.

Finally, there are several initiatives directly related to the discharge process that have demonstrated resounding success in peer-reviewed studies.  As above, collaboration is key prior to discharge, with patient education playing a critical role.  Home visits and telephone calls (as well as remote monitoring, if possible) are successful factors when used in a multidisciplinary, multi-pronged approach to aftercare.  Concurrent intervention seems to methods have been demonstrated to work far better than a simple or single-pronged approach to aftercare in terms of a patient's continued health, satisfaction, and potential hospital readmission.

About the Author

Christy Rakoczy has a JD from UCLA School of Law and an undergraduate degree in English Media and Communications from University of Rochester. Her career background includes teaching at the college level as well as working in the insurance and legal industries. She is currently a full-time writer who specializes in the legal, financial and healthcare sectors. Ms. Rakoczy writes online content as well as textbooks for adult learners.