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Are You Actively Preventing Hospital Readmissions?

The recent round of reimbursement penalties assessed by the Centers for Medicare and Medicaid Services (CMS) have increased focus on readmission rates and patient satisfaction scores. According to a recent study in the Harvard Business Review, for hospitals that already comply with evidence-based standards of care, a quality improvement program focused on improving communication with patients could markedly improve a hospital’s performance on both metrics.1

Based on a review of six years of data from nearly 3,000 acute care hospitals across the U.S., researchers found that prioritizing improved communication between care teams and patients could reduce readmission rates by 5% and protect the current 1.5% of Medicare reimbursements hospitals have at risk if those hospitals do not also show improvement in their patient experience scores. Those patient experience scores will become more important in coming years; by 2017, hospitals that fail to improve those scores will put 2% of their Medicare reimbursements at risk.

What can hospitals do better to improve care coordination while improving communications and reducing avoidable readmissions? Four hospitals with exceptionally low readmission rates offer some insights.2

These hospitals had readmission rates for heart attack, pneumonia and heart failure 2%-3% less than the national average. They shared six key practices:

  1. Invest in the tools and resources needed to properly care for patients. Top performing hospitals may extend the roles of nurses and hospitalists to educate patients or involve clinical pharmacists more directly in discharge planning and advanced medication review.These hospitals invest in automated tools that support their care teams, enabling them to more easily adopt process-of-care measures.

  2. Use health information technology (HIT) to ensure standardized, high quality, integrated care. HIT includes a range of systems and tools, including electronic health records, centralized data warehouses, electronic surveillance systems and clinical decision support systems, all of which can help clinicians at the point of care. Increasingly, hospitals are implementing automated systems that enable them to analyze in real-time data pulled from multiple systems to identify and prioritize high-risk patients, leading to reduced rates of healthcare-associated infections and adverse drug events as well as better planning for post-discharge care. Clinicians rely on these systems to ensure they provide care in keeping with current guidelines and hospital policies.

  3. Initiate care management and discharge planning early, particularly for high-risk or vulnerable patients, and engage the entire care team and the patient in the process.

  4. Communicate with the patient before and during their visit. Clearly explain care instructions and what symptoms indicate a problem in a language that patients (and those who will care for them after discharge) understand. The Harvard Business Review researchers found that when hospitals had high quality processes-of-care and then focused on improved communication, they achieved a 5% reduction in 30-day readmission rates; those that focused on responding more quickly to explicit patient needs experienced a 3% reduction.

  5. Provide an avenue for high-risk patients to stay in touch with hospital caregivers after discharge, whether through a patient portal, telemonitoring or phone calls.

  6. Work with community providers to align care to keep patients with chronic illness out of the hospital and ensure that the primary care provider knows why the patient was in the hospital, what the patient needs to do at home, and when the patient should be seen for follow up. Hospitals may do this as part of integrated healthcare systems or through well-developed, less formal means ensures that primary care providers and others involved in a patient’s post-discharge care receive the information they need to provide care on a timely basis.

How has your hospital improved communication with patients? Have you taken other steps for reducing or preventing hospital readmissions?



  1. Sinot C, Chandrasekaran A. What Has the Biggest Impact on Hospital Readmission Rates. Harvard Business Review. September 23, 2015.

  2. Silow-Carroll s, Edwards JN, Lashbrook A. Reducing Hospital Readmissions: Lessons from Top=Performing Hospitals Synthesis Report. The Commonwealth Fund. April 2011.

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