Helping patients stay out of the hospital once they've been discharged has been a longtime quality-improvement priority for many hospitals and health networks. Now it's become a financial priority, too, thanks to provisions of the Patient Protection and Affordable Care Act that set penalties for hospitals with higher-than-average rates of avoidable readmissions for patients with specified conditions.

The key word is avoidable. Medical experts say a zero rate of readmissions is not only impossible to achieve, it would not be desirable. Many readmissions are pre-planned for necessary follow-up care, such as chemotherapy treatments for certain cancer patients. A large percentage of readmitted patients are elderly, have multiple chronic conditions, and face complex and sometimes confusing medical regimens when they return home.

What's more, penalizing providers indiscriminately for all readmissions might discourage some from bringing patients back even when it would be appropriate.

Nevertheless, health care professionals agree that many readmissions would not be necessary if planning for post-discharge started early, was much more robust and thorough, actively involved the patient and her family, created a strong partnership with all post-acute care providers and was based on a hospital's own data as well as evidence-based best practices culled from national quality projects.

Here's a snapshot of the issues surrounding avoidable readmissions—why they are a concern, how you can understand their impact specifically on your hospital, and how tools like the Health Care Leader Action Guide to Reduce Avoidable Readmissions can help you achieve this particular quality-improvement goal.

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Sources: 3M Company analysis of 2005 Medicare discharge data; MedPac Report to Congress, June 2007

Three Guiding Principles

  1. Coordinate post-hospital care across settings.
  2. Take quick action to reconcile patient medications and schedule follow-up appointments with primary care physicians and specialists.
  3. Engage patients and families to play active roles in managing their health needs.

Source: California HealthCare Foundation, 2010

Checklist: Developing a Detailed Picture

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As part of the STate Action on Avoidable Rehospitalizations (STAAR) initiative, hospitals in four states—Massachusetts, Michigan, Ohio and Washington—in January began using a worksheet to track their five most recent rehospitalizations.

The worksheet begins with nine questions about each of the readmitted patients.

  1. What was the number of days between the last discharge and this readmission date?
  2. Was the follow-up physician visit scheduled prior to discharge?
  3. If yes, was the patient able to attend the office visit?
  4. Were there any urgent clinic/emergency department visits before readmission?
  5. What was the functional status of the patient on discharge?
  6. Was a clear discharge plan documented?
  7. Was evidence of "teach-back" documented?
  8. List any documented reason(s) for readmission.
  9. Did any social conditions (transportation, lack of money for medication, lack of housing) contribute to the readmission?

Source: Commonwealth Fund and the Institute for Healthcare Improvement, 2010

Key Stages of the Care Delivery Process

The Health Care Leader Action Guide to Reduce Avoidable Readmissions from Hospitals in Pursuit of Excellence describes a step-by-step routine that hospitals and other providers should take at three points in the care delivery process. The guide can be downloaded at

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Source: Health Care Leader Action Guide to Reduce Avoidable Readmissions, Hospitals in Pursuit of Excellence, 2010