• by Daniella Koren , September 26, 2014

According to the Centers for Medicare and Medicaid Services (CMS), about one in five Medicare patients discharged from a hospital is readmitted within 30 days. In an effort to change this, in 2009, the CMS began publicly reporting hospital readmission rates for certain conditions, and the Affordable Care Act contains multiple payment reforms intended to promote hospital efforts to address and prevent adverse events after discharge. Chief among these are financial penalties for hospitals with above-average readmission rates for certain illnesses. 

One important way for hospitals to reduce readmissions is to change the patient discharge process. Subject to the doctor’s schedule, a hospital discharge often comes with little or no warning, so a caregiver may not be present to ask questions and get instructions. The discharge itself is often a rushed event in which the doctor, nurse, and other staff provide verbal and written instructions, which may or may not be consistent with one another. 

This disconnect continues once patients get home. When patients are in the hospital, they are monitored routinely, but at home they are either not monitored, or are monitored by a non-hospital care provider who may not be aware of the patients’ specific needs after their hospitalization.

The results are predictable. A study in the Annals of Internal Medicine of 400 patients found that 19% had an adverse event within one month of being discharged from the hospital. Of those events, a third could have been prevented with better monitoring or earlier response. The study also found that the most common issue at discharge was lack of communication between the hospital healthcare providers and either the patient or the patient’s primary care doctor.

In addition, nearly 40% of patients are discharged with test results pending, and a similar number are discharged with a plan to complete the diagnostic workup as an outpatient, which leaves patients in need of follow-up.

How did we get here?

For hospital-based doctors, preparing a patient for hospital discharge takes time, especially when it includes performing medication reconciliation, patient education, and discharge summary documentation—and time is the one thing that doctors are chronically short of. In addition, most doctors have not received specific training on how to best discharge a patient. 

A systematic review of discharge communications, conducted by the joint Society of Hospital Medicine/Society of General Internal Medicine (SHM/SGIM) Continuity of Care Task Force, revealed that discharge summaries are usually unavailable at the time of the first follow-up contact, and this adversely affects care in about one-fourth of patients. To make matters worse, discharge summaries often lack information that would be essential for providing good follow-up care, such as discharge medications (missing from an average of 21% of discharge summaries), pending test results (65%), and follow-up arrangements that were made or need to be made (14%). When chronic outpatient medications are changed during the hospitalization, the rationale for such changes is also usually not provided.

What hospitals and doctors can do

Two studies, the CARE Transitions trial and the Project RED study, successfully reduced hospital readmissions by using either “transition coaches” or specially trained nursing staff to meet with patients before discharge to evaluate medications, instruct patients and caregivers in self-care methods, prepare patient-centered discharge instructions, and facilitate communication with outpatient doctors.

The interventions that were used—which other hospitals and healthcare providers can emulate—include:

• Educate the patient about their condition and treatment throughout the hospitalization. 

• Organize and schedule post-discharge appointments. 

• Give the patient a written discharge plan that includes the reasons for hospitalization, instructions for following the medication regimen, recommendations on what to do if the condition worsens, follow-up appointments, and any pending items such as test results. 

• Prepare a detailed discharge summary and deliver it promptly to the primary care doctor. 

• Reinforce the discharge plan and provide troubleshooting by phone two to three days after discharge.

By improving the discharge process and ensuring that patients have all the information they need before they leave, hospitals and patients can both improve their outcomes.