OpenPlacement Community > OpenPlacement Blog > Reducing Readmissions: A 360 Perspective

Reducing Readmissions: A 360 Perspective Christy Rakoczy

May 2nd, 2013

360The high number of readmissions within 30 days is an issue that all hospitals are currently seeking to analyze and improve. In order to do so, it is crucial to assess and improve current practices and develop innovative new policies and procedures that will help patients to recover quickly without need for readmission within a short period of time.

The Importance of Reducing Readmissions

Currently, about one in five Medicare patients are being readmitted to hospitals within 30 days due to secondary conditions that have arisen since discharge after treatment of an initial condition such as heart failure or pneumonia. To reduce this number, hospitals have begun to modify and improve patient care while the patient is hospitalized as well as after the patient has been discharged.

The number one cited way to reduce readmissions is to ensure top quality care while the patient is hospitalized. By ensuring that patients receive the correct diagnosis, appropriate treatment, and correct medicine, readmission rates can be greatly reduced. Additionally, attending to patients’ basic needs such as sleep and nutrition helps patients to build the strength to recover without acquiring a secondary condition.

More Tools for Reducing Readmission

While providing care in hospitals is important, there are also many different things that need to be done once the patient is no longer under the hospital’s care.

One of the number one ways to reduce readmission rates is to provide patients with follow up support after they have been discharged. Many hospitals call these “coaches.” The coach’s sole position is to routinely follow up with patients over a period of time until the patient has recovered. Follow up begins by phone or in person within 48 hours and can last as long as necessary. Some of the responsibilities of a coach may include discussing pain, verifying that patients are taking their medicine, confirming the effectiveness of the prescribed medication, helping to make follow up appointments with specialists or primary care physicians, inquiring about any possibly complications, and overall insurance that patients have the tools and education to move forward with recovery.

Another important technique hospitals must employ in order to help patients to recover and improve their health is to provide adequate education. Helping patients to identify lifestyle choices that may have put them at risk for the condition that caused their hospitalization can assist patients in making healthier choices that prevent future hospital visits. Additionally, educating patients on resources that they can access after discharge such as nutritionists or smoking cessation programs can give patients the tools they need to be successful in improving their health and achieving a quick recovery.

A final change that successful hospitals have made in order to reduce readmissions is creating alignment with community care centers. By aligning with other doctors and specialists in the community and by using hospital information technology, patients can receive a “continuum of care.” This will allow hospitals to immediately recommend specialists or primary care physicians to patients upon discharge. Those community care centers then have immediate access to patient files to understand the care that has been provided and to be able to appropriately move forward in helping the patient. The transition from hospital to community doctors is seamless for the patient and saves time for both patients and doctors.

By looking both within and outside the hospital a holistic approach at improvement can be achieved and hospital readmission rates can be successfully reduced by every hospital.


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.



  1. Dan Trigub May 3, 2013

    Christy makes some great points here. Would love to hear some feedback from any discharge planners or case managers out there. Let us know your thoughts!

  2. Aaron Davis May 6, 2013

    Yes, excellent points. In my field, I work solely with preventative health measures, so my perspective is, let’s try to keep them out of the hospital in the first place. I think every idea in this article is a great one, but wouldn’t it be even better if hospitals made such initiatives available and accessible to the general public, not just discharged patients?

  3. Shawn Whatley May 6, 2013

    Good thoughts, Christy.

    Is readmission after a trial of discharge a bad thing? If we have zero readmissions, maybe we aren’t discharging soon enough?


    1. Ninette Tan May 7, 2013

      Great question Shawn. Most hospitals are penalized for re-admissions because they may indicate the patient either did not receive adequate discharge education or a health issue was not adequately addressed when admitted. We have to look at the reasons patients are being readmitted for. There are high risk conditions medical professionals are aiming to prevent exacerbation in such as CHF, Diabetes, high blood pressure. Any readmissions as a result of complications in these conditions reflect poorly on the facility especially if it is within a short period of time.

  4. Lisa May 7, 2013

    Good proactive points to address an apparent problematic issue.

  5. Jim Katzaman May 7, 2013

    It would seem pretty intuitive: Treat properly, and be sure patients follow up with their doctor or healthcare professional. Then again, maybe it’s not that intuitive if the process hasn’t been used.

  6. Rhonda Hiltbrand May 8, 2013

    Excellent points. I know insurance is very anxious to get patients out the door of the hospital or rehab centers and sometimes I feel it is very premature and puts a tremendous pressure on their families to provide nursing care when they don’t have those skills. It also causes those family members to have to miss work, etc.

  7. Stephen Cowen May 9, 2013

    Good article. I would add that when someone leaves the hospital while still in some level of weakened state due to illness or injury make sure good physical assistive devices are in place to lessen the risk of injury and discomfort to the individual or their caretakers.

  8. MaryAnne Sterling May 13, 2013

    Great dialogue that we need to continue! I would add the tremendous need for connecting healthcare with social services and community supports. Also the critical need for educating the family caregiver (in addition to the patient).

  9. Joanne Handy May 14, 2013

    I spent much of my career in the home health arena and I think that the increased attention to care transitions (a good thing) is due to the shortcomings of communication between acute care and home health care. The high risk patients targeted by transitions programs are the same ones referred to HHAs post-hospitalization. If communication between ‘silos” was stronger, we wouldn’t have to create an entire new level of “transition coaches” to fix the system. This seems like a work-around not a true solution.solution. A good home health nurse, visiting within 24 hours of hospital discharge, should be able to address the transition issues, given effective communication with the hospital. The fact that it is necessary saddens and frustrates me.


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