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Preventable Readmissions Possible with This Care Model


Preventable hospital readmissions, an objective measure of quality, have long been a concern for health plans. Here’s a care plan that could be the solution.

Melinda Henderson


Preventable hospital readmissions, an objective measure of quality, have long been a concern for health plans. Each unnecessary readmission costs on average $14,000 and there are more than 2,000,000 each year. In addition to increased costs, preventable readmissions are also associated with increased morbidity and mortality and, as an important Medicare quality measure, a reduction in STAR ratings. Beginning in 2013, the ACA included disincentives in the form of reduced Medicare reimbursement to hospitals with readmissions above specific levels for a targeted group of diagnoses. Initially, readmissions began to decline slightly but more recently they’re trending higher. What can a health plan do to respond?

The simple answer is preventable readmissions are the result of a failure in the transition of care from an inpatient facility to another setting. These readmissions are often the result of not identifying those patients who are at a high risk because of age, comorbidities, socioeconomic status, social determinants of health, social supports and a history of behavioral health diagnoses. Other contributing factors, at the point of discharge from a hospital, include a lack of out-patient work-up, incomplete test results, or a discharge summary either not readily available or lacking key components. In addition, failure to provide adequate post-discharge information to the patient and their family or the lack of follow-up can lead to avoidable readmissions.

Impacting unnecessary readmissions requires that health plans take a greater role in the oversight of the hospital discharge process, beginning as soon as a patient is admitted. This includes requiring network hospitals to focus on patient risk assessment, patient/family education about therapies, education on medications and treatment side effects, as well as a clear commitment to post-discharge services including follow-up with the patient. Employing evidence-based programs such as Eric Coleman’s Care Transition Program, the Transitional Care Model, Project RED or Project BOOST increases the opportunities for successful discharges. Finally, it is critical to use a validated readmission tool such as LACE or HOSPITAL to assess the potential for a patient’s likelihood of readmission. 

Once discharged, an effective transition of care program should assure the provision of appropriate care for at least 30 days following post-hospital discharge. This should include patient outreach and in-person follow up within 72 hours of discharge, care coordination, provision of care including closing care gaps, and support coordination with all members of the patient’s care team.  Increased direction, beyond a traditional in hospital discharge is critical to ensure common causes of readmission are avoided, including ensuring prescriptions are filled and DME is delivered. More recent research has demonstrated social supports like personal care aides and meal delivery can also reduce readmissions.   

Addressing the issue of preventable hospital readmissions requires the commitment of a health plan’s provider network and clinical teams to be involved in the oversight of a patient’s care from hospital admission through their successful transition to a home or other setting. Because of the significant investment in specialized tools and staff required for preventing unnecessary readmissions, many health plans partner with organizations who have developed this expertise to achieve greater success in this area. No matter how a health plan approaches this issue, the importance of reducing unnecessary expense and poor member outcomes cannot be overstated.


Melinda Henderson, MD, chief medical officer of PopHealthCare, is a board-certified internal medicine, geriatric and hospice & palliative medicine physician. She is experienced in Medicaid and Medicare managed care and is a fellow of the American Academy of Hospice and Palliative Medicine and a Certified Medical Director with the Society for Post-Acute and Long-Term Care Medicine. PopHealthCare provides physician led teams to support individuals with complex conditions with in-home care, including post-acute care.


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