OpenPlacement Community > OpenPlacement Blog > Readmission & The Common Reasons

Readmission & The Common Reasons Mary Bommel Shames

October 25th, 2013

Readmission (10.26.12)With the advent of the Affordable Care Act (aka Obama Care), it is crucial for hospitals to prevent readmissions to the best of their abilities. Under new law, hospitals with an unacceptably high level of readmissions within 30 days can result in financial penalties that many hospitals cannot afford to sustain.

So, what is causing hospital readmissions? Why are patients who seemed to be well upon discharge being readmitted?

Readmission Reason #1: Poor Communication With PCPs

Patients may be admitted to the hospital for various reasons, some of them life-changing. Often, upon discharge, patients are expected to return to their Primary Care Physicians (PCPs) for follow up care. However, if the hospital and the patient both fail to communicate with the Primary Care Physician, this part of the process can easily fall apart. If the hospital fails to communicate, the Primary Care Physician fails to have record of the tests, findings, diagnosis and prognosis of the hospital physicians. If the patient fails to follow up, there is no means of ensuring the level of pro-discharge care is being met.

Readmission Reason #2: Poor Discharge Practices

When a patient is discharged, he is given information on how to care for himself, or for caregivers to care for him. Often, discharge papers can be unclear if not explicitly explained by doctors or nurses. This results in poor after-care and the necessary return of a patient.

Readmission Reason #3: Lack of Understanding of Patients’ Circumstances

A doctor or nurse can recommend a patient to visit myriad doctors or providers of other services. However, if the care providers do not consider the situation of the patient, these words will fall on deaf ears. For patients unable to transport themselves, or cannot for any number of reasons, independently visit the recommended follow up care, then it is of little use.

Readmission Reason #4: Cultural Needs

Often, in a multicultural society, it is necessary to consider the needs of patients and adjust medical advice appropriately. If the advice of the doctor is not cohesive with the religious, spiritual or personal beliefs of a patient, the recommendations need to be re-evaluated to ensure the patient’s success in properly healing.

Readmission Reason #5: Implementation of Home Health Services

A significant way to reduce readmissions is to employ the use of home health services. Organizations like Visiting Nurse Association can visit the home and help with any care necessary. From wound and ostomy treatment to admission of MS medications via IV, home health nurses can provide amazing care that can prevent many from returning to the hospital.

Overall, there are a variety of ways to reduce readmissions, and most are not particularly difficult or time consuming. By improving verbal and written communication, employing empathy, and increasing awareness of patients’ varying needs, hospital readmissions can be greatly reduced.


  1. Mario G. Giorgianni, M.D. October 26, 2013

    Many good points made here. Other reasons include patient non-compliance; what is the condition of the home the patient is going to, what is the support system at home, etc. I’m not sure that patients are discharged well from hospitals. as stated above. There is such a push to get patients home asap with a constant pressure that there is documentation to justify a patients stay in the hospital. I think it is difficult for patients and families to know exactly what is going on as they are given lots of paper with information and instruction – sometimes the critical stuff they need to know is lost. I do know that communication to the PCP is often lacking. Overall, the issues of hospital readmissions is complex with more factors than noted in this blog and by me.

  2. Patricia player Maxwell October 26, 2013

    Thank you . Good examples.
    The discharge process is too disjointed. Oftentimes the Discharge planner or Case Manager comes to the patients room and talks actually tells the patient they will soon be discharged. The patient is alone and maybe unable to process this information or in some cases unable to remember anything that was said.
    First make sure someone is with the patient to be their eyes and ears.
    Secondly have clear concise instructions in the language of the patient.
    Three do not rush the discharge process.
    Four be absolutely sure that the conditions at home are suitable for discharge. When discharging patients to skilled nursing, for Pete’s sake do not just go from your list. Half the time patients are discharged to places unsuitable for their specific needs. Half the time the individual has never set foot in the places to which they are sending the patient. If they did half of the so called skilled nursing establishments would be closed.

  3. Ellen Honig October 26, 2013

    As was commented above, there are many reasons why patient are readmitted to hospitals. Some additional thoughts.
    Communication, communication and more communication. Not just with the PCP, but with any post-acute providers that patient had been referred too. This type of communication is moving to an electronic platform, rather than paper. (Disclosure, I work for Curaspan Health Group, an electronic Transition Management Company) This type of communication between the two entities is HIPAA compliant, secure and instant.
    Patient and family responsibility: The patient/family group needs to be compliant with the instructions given to them at discharge. For this to happen not only must the instructions be in a language that they can read but at the level of understanding that they have. Too often the medication information is complicated and difficult to understand. The nurse/discharge planner needs to be sure the patient understands the instructions given to them. As we all know, the patient is under stress and may not understand/retain what has been told to him/her.

  4. Peggy D. Arnold, CSA October 28, 2013

    I’ve had a loved one discharged twice from the hospital – once for a heart attack that ended up with quad bypass surgery plus pacemaker implant and once for a stroke. Thank goodness I’m in the health field but even so, I was shocked at how we were rushed through the discharge process both times. Not only is there a discharge planner going through all the paperwork quickly but now you are also dealing with a loved one who wants to leave immediately because they want to go home!! Talk about stress! There has to be a better way of handling this process. Communication is always key but another area that is often overlooked is what kind of support system will the patient have when discharged to their home. Unless there is someone there 24/7 to make sure they are following the discharge instructions, the patient will most likely become ill again. They forget to take their medications as instructed and are too weak to take care of themselves such as the ability to fix nutritious meals, bathing/toileting, getting dressed and personal grooming. The best way to keep a patient from being readmitted to the hospital is a good support system in place at their home and good follow-up by the physician. Again, it is the support at home that will make sure the appointments are kept and communication is flowing between patient and physician. In my opinion, until we figure out a way to ensure patients received this type of care in the home, we will continue to have re-admittance issues.

  5. Barbara Fiorica, The Elder Care Team October 29, 2013

    I feel the lack of communication among nurses, PCPs, Hospitalists, Case Managers, therapists and the patients and their families is sorely lacking in many cases. Sometimes one hand doesn’t know what the other is doing, there may be a language barrier among staff and/or the patient, and the patient may not truly understand the discharge procedure, even thought they say they do out of embarrassment. The rush to discharge early to get new butts in the bed to fill quotas is also a problem. It’s been a business focused on bottom line, rather than the overall well-being of the patient. There is lack of continuity of care should the patient have to recover in a skilled nursing facility after discharge (snf). While Home Health is generally covered by Medicare and Supplemental insurances, it is only provided for a limited time, and must be constantly re-justified to the PCP for the service to be reordered. Should the patient require Home Care, this is not covered by insurance and the patient may not be able to afford such coverage. If they live alone, with no one to monitor their meds and discharge instructions, chances are they will end up being readmitted. We are moving too fast, and with speed, more mistakes are made landing the patient back in the hospital. We need to slow down a little to make sure that proper instructions are being given, that medications are prescribed that don’t cause serious side affects that will send the patient to the E/R, and that the patient understands what is expected of him and of his follow-up care. A Case Manager would be of great assistance in these matters so that care can be coordinated among the various dynamics, with less of a chance of readmittence.

  6. Ann Rosas October 30, 2013

    I work for a non-medical home care agency and we always ask to be involved in the discharge planning meeting for a client. Hearing first hand from the medical team about our client’s needs post-hospital or post-rehab is a great way to insure that we know what is needed at home. I connect with all other resources at home; Skilled Nursing, PT/OT, and Hospice to coordinate care and make sure we are all on the same page for good care. My caregivers may be ‘non-medical’ but if they are involved with a client, they may be the first/best ones to note a change in health status. A team approach at home helps clients and families.

  7. Pat Meier October 30, 2013

    Thank you Mary Shames for this blog. I believe the blog provides nurses and case managers from different settings an excellent forum to exchange invaluable insight.
    I work as an oncology case manager for employer funded health plans. It is the most rewarding and challenging position of my career. Once I am assigned to a person with a cancer diagnosis, I follow through until they no longer need assistance with coordination of services. Health plan CMs can be an (unrecognized) asset to hospital discharge planners, office nurses and home health providers. Besides helping identify in-network providers for discharge needs, the CM can often provide information from working with the patient over time that helps identify discharge needs. After discharge, through follow-up calls to the patient/family, the CM can review/reinforce teaching and help a patient problem-solve symptoms or whether to contact their physician. Patients usually know their health plan CM by name and may even have brought the CM contact number along to the hospital. The health plan CM follows up with outpatient providers and may suggest additional services such as skilled nursing visits or ask the clinic nurses about availability of community resources.
    In the past year I have read about 2 research studies that support the benefit of health plan CMs. I believe it was a University of Pennsylvania study that found the benefit for Medicare patients being followed by a CM for at least a month after discharge. Another study described patients’ past perception of insurance company CMs as ‘angles of death.’ Now patients often perceive their health plan CMs as ‘guardian angels.’ Staff of employer funded health plans often know patients and want the best for them. Likewise they recognize the value of services that that keep patients healthy, thereby averting avoidable re-admissions.
    I hope this dialog continues and additional persons can provide insight from their career or personal life experience.

  8. Max Greenberg October 31, 2013

    Another way hospitals are cutting down on readmissions is to not admit the patient in the first place. They sign them in “Under Observation”, thus when they are discharged and need to come back for the same health issue, their second visit is not considered a readmission. Not only has the hospital avoided the penalties for readmission, but the cost of rehab is shifted on to the patient, which might be a leading cause of heart attacks when the patient opens up the envelope and sees that his rehab following coming into the hospital with “Under Observation” status is not covered by Medicare. This is a practice that must be stopped.

  9. Alan November 6, 2013

    I am fascinated by this, and we did a very comprehensive (medically acute 131 bed SNF) with the admin and an exceptionally bright RN. In just one slice, we found the readmission always occurred for a diagnoses other than what the SNF admit was for….i.e. a knee replacement would go out for respiratory…in a tiny example, we started treating for the known risk (pneumonia, acquired) versus waiting for a DX which would bounce the resident…we eliminated readmissions…

    1. Glenda Hynes November 16, 2013

      Alan makes a vitally important statement here. When a patient with multiple medical diagnoses or chronic disease conditions is transferred to a SNF for a primary diagnosis such as knee replacement, skilled observation of signs & symptoms of the secondary & chronic conditions must begin o n day of one of SNF admission. My clients follow the PREDICT, PLAN, PREVENT approach that encompasses treatment, observation & management of all diagnoses & potential complications. in addition using INTERACT #3 training & processes patient exacerbations of chronic illnesses and complications are prevented or treated early preventing re-hospitalization. Hospital discharge planners should consider a short SNF stay as a transition between hospital and home care for these high risk patients.

  10. Ellen Mininberg-Scott RN BSN November 13, 2013

    I also would like to chime in. I have worked for the hospital and the insurance company. I believe Medicaire has been a large part of the problem. They brought us the ” no re- admit for the same diagnosis within 30 days”. If it they do, the hospital has to eat the admission. Also the observation that goes for 48 hours instead of 23 hours. It has gotten so difficult for the patient to get the care that he or she needs.

    I have also seen on the insurance side, policy / procedures taken so literally. For instance Milliman is used as exact words, no as a guideline. It is difficult.
    What I do see is a common thread. Families all want someone else to care for there loved ones. States even pay families to care for Medicaid/ Medicaid. Patients. I received a lot of these patients in the ER on a Friday night .

    We need more communication between families/ CM/ hospitals / PCP and ancillary facilities when the patient goes home. Reporting from CM to the next care instatute they set up for discharge. Also, was this discharge understood, and is it safe.

    I am proud of one program I started on my own when I worked with insurance companies. The hospital CM had a direct contact in the insurance company, such as the UR CM , to help in the discharge plan. Then the Ins. CM became a part of the rounds giving them ideas what is available for them. Continuously being a team.

    Yes the patient must take responsibilities, yes the PCP has too, yes the family, the facilities and finally we say what could I have done more?

    The answer is ________. I left this blank because there is no one answer for each of us. But what I do think is team approach The tools we are given to do our job and maybe putting the physician back in the hospital to actually see his/ her patient instead of report.

    I do not know if any of this is correct, but it good they we are all talking, Now we need to try to make changes. I hope I can continue to make changes. I hope to continue to be a voice.


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