1. Clancy, Carolyn M. MD

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NURSES, other health care and quality improvement professionals, and health care executives across the country are focusing more-than-usual attention on identifying the factors that cause a high volume of hospital readmissions. Their activity is being driven in large part by the Hospital Readmissions Reduction Program, which was enacted as part of the Affordable Care Act. Effective October 1, 2012, organizations with high 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia could see their annual hospital Medicare payments reduced by up to 1%, according to a final rule from the Centers for Medicare & Medicaid Services (CMS).1


Hospital readmissions occur frequently, have major cost and quality implications, and can often be prevented. A major study2 found that nearly 1 in 5 Medicare patients discharged from the hospital is readmitted within 30 days, 1 in 3 within 90 days, and more than half within 1 year of discharge. Readmissions among Medicare patients within 30 days accounted for about $17 billion of Medicare spending, with much of it preventable, according to a Congressional advisory panel.3


To be sure, not all hospital readmissions for every patient can be prevented. However, policy makers, clinicians, and quality improvement experts agree that frequent readmissions, especially for patients with chronic conditions, suggest poor care coordination that often leaves patients vulnerable to repeated hospital stays and worsening outcomes. In response, several public and private entities, including the Agency for Healthcare Research and Quality (AHRQ), the Partnership for Patients, the Society for Hospital Medicine, Medicare Quality Improvement Organizations (QIOs), and Patient Safety Organizations (PSOs), have developed tools, resources, and technical assistance to help nurses, quality improvement professionals, hospitals, and communities understand and address the factors leading to frequent readmissions.



Higher-than-average readmissions for Medicare patients with myocardial infarction, heart failure, and pneumonia are not limited to certain types of hospitals or to specific regions of the country. Instead, they occur in hospitals of different sizes and in virtually all states, according to data reported to Hospital Compare and analyzed by the CMS.4 Data from Hospital Compare and Medicare claims from 2008 to 2011 (except from the state of Maryland, which is exempt from the Medicare payment system) were calculated to arrive at states' average readmission rates and excess readmission rates for the 3 targeted conditions. Hospitals in each state were identified as having a high readmission rate if they fell in the worst quartile for all 3; additional hospitals were identified if they fell in the worst quartile for any 2 of the 3 conditions.


Nationally, a total of 138 hospitals were found to be in the worst quartile on all 3 readmission rates, according to an evaluation conducted by the CMS.5 An additional 438 hospitals had readmissions rates in the worst quartile on 2 of the 3 conditions; these hospitals were located in every state except Alaska. All told, 631 hospitals had readmission rates in the worst quartile on 2 or more conditions. These hospitals are eligible to partner with organizations in their community to participate in the CMS' Community-based Care Transitions Project, which provides funding to test models for improving care transitions for high-risk Medicare patients.6 Up to $500 million is available for this project through 2015. The project is also part of the work of the Partnership for Patients, a public-private partnership that aims to reduce hospital readmissions by 20% by 2013.


Medicare QIOs can assist hospitals and community-based organizations that want to apply or participate in the Community-based Care Transitions Project. Specifically, QIOs can provide community-level readmissions data and analyze trends, conduct community-specific root-cause analyses and help select appropriate interventions, and convene community partners and provide technical assistance.7 Quality Improvement Organizations are also providing technical assistance to hospitals on how to prevent readmissions as part of their ongoing work for Medicare.



For years, the AHRQ has supported research that seeks to reduce hospital admissions and can spread that knowledge through training and tools. For example, the agency funded the initial research of AHRQ grantee Brian Jack, MD, at Boston University Medical Center. Published in 2007, his research demonstrated that patients who are discharged from the hospital with a clear understanding of their after-care instructions are 30% less likely to be readmitted within 30 days or visit the emergency department than patients who lacked this information.8


Key elements of Project RED (short for the Re-Engineered Discharge) include


* educating the patient about his or her diagnosis throughout the hospital stay;


* making appointments for follow-up and testing;


* confirming the medication plan and making sure the patient understands it; and


* contacting the patient 2 to 3 days after discharge to identify and resolve any problems.



More than 260 hospitals have received technical assistance to use Project RED in whole or in part; it is now available as a training program.9


The AHRQ also funded a research project by Mark V. Williams, MD, now at Northwestern University Feinberg School of Medicine, Chicago, Illinois, on how to improve the hospital discharge through medication reconciliation and education. Findings from that project helped inform the development of Project BOOST (Better Outcomes for Older adults through Safe Transitions), which reduces readmission rates by providing clinicians with resources and expert mentoring, enhancing patient and family education, and improving the flow of information among health care providers in the inpatient and outpatient setting. Preliminary data from hospitals that have implemented Project BOOST show a 21% reduction in 30-day all-cause readmission rates. A toolkit is available through the Society of Hospital Medicine.10


Patient Safety Organizations

Patient Safety Organizations are another valuable resource for hospitals seeking to understand and address factors leading to higher-than-average readmissions. Administered by the AHRQ, PSOs were created as a mechanism to allow clinicians and health care organizations to voluntarily report, share, and learn from patient safety information without fear of legal discovery. Currently, 76 PSOs are listed by the AHRQ and operate in 30 states.11


Through Common Formats, or the common definitions and reporting formats that allow health care providers to collect and submit standardized information about patient safety events, PSOs will be able to assist hospitals seeking more information about readmissions.12 A Common Format for Readmissions developed by the AHRQ will allow hospitals to aggregate data on the characteristics of patients who have been readmitted, including factors such as the actions taken at the index hospitalization to prevent a readmission, risk factors for readmission, length of stay, presence of an adverse event, location of discharge setting, and the like. The standardized Common Format allows hospitals to compare their data to others and identify patterns that could lead to fewer readmissions and improved outcomes. The beta version of the Common Format for Readmissions was published in mid-July and was open for public comments through September 20, 2012.13



Over the past 3 decades, hospitals have responded aggressively to Medicare's financial incentive to treat and discharge patients to less cost-intensive settings. Readmissions, although not welcome from a quality standpoint, posed no financial risk to an organization. Nurses and quality improvement staff attempting to intervene on patients' behalf had not been routinely supported.


That dynamic is poised to change. Hospitals must learn to maintain effective and consistent levels of nurse staffing, which has been shown to decrease preventable readmissions,14 and to invest in nurses' capability to educate patients. Evidence-based research from the AHRQ and others can help identify patients' needs as they leave the hospital and point to resources that can help meet them. For conditions that are the cause of frequent hospital readmissions, Medicare's new payment policy is beginning to align financial and quality of care incentives in the same direction.




1. Centers for Medicare & Medicaid Services. Final rule, August 31, 2012, Medicare program; hospital inpatient prospective payment systems for acute care hospitals, etc. Fed Reg. Accessed August 27, 2012. [Context Link]


2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare Fee-for-Service Program. N Engl J Med. 2009;360(14):1418-1428. [Context Link]


3. Medicare Payment Advisory Commission (MedPAC). Report to Congress: promoting greater efficiency in Medicare, June 2007, chapter 5. Accessed August 27, 2012. [Context Link]


4. Centers for Medicare & Medicaid Services. Readmissions Reduction Program. Accessed August 27, 2012. [Context Link]


5. Centers for Medicare & Medicaid Services. Community-based Care Transition Program. Overview: fourth quartile, hospitals by states. Accessed August 27, 2012. [Context Link]


6. Center for Medicare & Medicaid Innovation. Community-based Care Transition Program. Accessed August 27, 2012. [Context Link]


7. National Coordinating Center for Integrating Care for Populations and Communities. Accessed August 27, 2012. [Context Link]


8. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187. [Context Link]


9. Agency for Healthcare Research and Quality. Project RED (Re-Engineered Discharge Training Program). Accessed August 27, 2012. [Context Link]


10. Society of Hospital Medicine. Quality Initiatives for hospitalized patient care. Accessed August 27, 2012. [Context Link]


11. Agency for Healthcare Research and Quality. Patient Safety Organizations. Accessed August 27, 2012. [Context Link]


12. Agency for Healthcare Research and Quality. Common Formats. Accessed August 27, 2012. [Context Link]


13. National Quality Forum. Comments on Common Format Readmissions Version 0.1 Beta and Version 1.2 (Hospitals). Accessed August 27, 2012. [Context Link]


14. Weiss ME, Yakusheva O, Bobay KL. Quality and cost analysis of nurse staffing, discharge preparation and postdischarge utilization. Health Serv Res. 2011;46(5):1473-1494. [Context Link]