Reducing Avoidable Readmissions is an Important Focus for Hospitalists

Now in its 13th year, Medicare’s Hospital Readmissions Reduction Program (HRRP) continues to incentivize hospitals to do a better job of coordinating the care of patients they are discharging to prevent unplanned readmissions. Medicare calls it a “value-based purchasing program,” linking payment to the quality of hospital care by penalizing hospitals with a higher-than-predicted rate of readmissions to any acute hospital within 30 days after discharge.

At least 93% of nearly 3,000 participating hospitals have incurred financial penalties on their Medicare reimbursement for readmissions for six specified conditions or procedures (see also sidebar on page X).¹ Penalties can be as high as 3% of their Medicare reimbursement but the average penalty is 0.64%.

Hospitals have tried a variety of measures to discourage avoidable readmissions, with greater success in reducing their rates in the early days of HRRP. Much of the focus has been on communication, care coordination, and discharge planning as primary strategies. But by now the low-hanging fruit has mostly been plucked, and further reductions have become harder to achieve.

Dr. Duggirala

Quality experts emphasize that hospitals and their hospitalists should aim not only to avoid HRRP penalties but also to enhance the quality of care for patients, who likely prefer to avoid rehospitalization when possible. Transparency is a cornerstone of this quality approach, said Vijay Duggirala, MD, a hospitalist and director of quality and patient safety in the division of hospital medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio.

Owning one’s readmission experience

“Transparency means saying, ‘This is our readmissions experience.’,” Dr. Duggirala said. “We share that information with our partners.” If the vast majority of hospitals have been penalized for excessive readmissions, he added, then it follows that they needn’t feel ashamed over it, he said.

“Does your institution push that information forward to your frontline providers and say to them: ‘Partner with us on improving the patient experience and ensuring that we have appropriate processes in place to prevent readmissions’? It’s important to understand what the baseline is. Let’s own it, let’s admit it, and let’s work together to make it better,” he said. “We don’t have the answers, but there are interventions that people across the country are doing. What we are doing here is based on what we’ve identified as best practices.”

Much of the readmissions focus at The Ohio State University Wexner Medical Center is on inpatient huddles, so everyone on the inpatient team understands what the plan is before the patient leaves. Discharge huddles for every patient on the general medical service are held daily in 15-minute increments and include nursing, case management, social work, rehabilitation and therapy, and the clinician team.

“We talk about barriers, for example: insurance limitations and social determinants of health,” Dr. Duggirala said. The focus on social determinants of health can offer a realization of what can or cannot be mitigated. For example, if the patient can’t get an appointment with a primary care physician, can they be connected with other medical services in the community?

The hospital team has also embedded phone calls to its patients after discharge. “We as an institution haven’t gotten as good as we’d like at reconnecting our patients back to their primary care physician within seven to 10 days of discharge, as recommended,” he said. In the meantime, there are navigators, such as the hospital’s heart failure navigator, who can call or schedule a visit to the heart failure navigation clinic.

Medication reconciliation is another key, evidence-based intervention in managing readmissions, Dr. Duggirala said. “We’ve identified that for most discharged patients, it’s better if they leave the hospital with all their medications in hand.”

The literature has shown that a significant proportion of readmissions can be attributed to medications, either errors on admission or omissions at the time of discharge from the hospital, while educating patients about their medications has been shown to make a difference in readmissions.² SHM’s MARQUIS 14-month medical reconciliation collaborative is an important tool for improving medication reconciliation, Dr. Duggirala said.³

Dr. Gundareddy

Venkat Gundareddy, MBBS, MPH, FACP, SFHM, associate director in the division of hospital medicine at Johns Hopkins Bayview Medical Center in Baltimore and a member of The Hospitalist’s editorial board, said he believes an understanding of readmissions has improved over the years of HRRP. “It is a metric that continues to be used by hospitals.” But there is also an appreciation by hospitalists and hospitals that not all readmissions are preventable.

Whose responsibility?

Historically, the healthcare system has attributed readmissions to the discharging practitioner, Dr. Gundareddy said. “But with the complexity of patients that we have today, it’s very difficult to say that one clinician is responsible. It’s the team that now needs to take ownership for readmissions.”

Johns Hopkins case managers and social workers have been using newer predictive tools to assess readmission risk. “In the future, we will be using AI,” he said. “But the question is, ‘Okay, if you can predict the readmission, what are you doing to prevent it? What does that gap or transition from the hospital to the primary care team look like?’ That is a field that needs to be explored more,” he said.

“There are models that are available for certain disease conditions, but we need to find new solutions to address the larger population. Do we really fully understand the psycho-social causes of readmissions, which may need to be addressed much further upstream and at the policy level?”

Among the things being done at Johns Hopkins is a health-system-level, congestive heart failure, clinical community through the Armstrong Institute for Patient Safety and Quality, which has developed a road map for heart failure patients across the continuum of care. “They’ve come up with metrics for everybody to own. We’ve set up transition clinics at our academic medical centers, and at the community hospitals, we partner with cardiologists to ensure that when patients are discharged, they will have a cardiology follow-up appointment within seven days,” Dr. Gundareddy said.

Length of stay versus readmission rate

Dr. Mehta

Arunab Mehta, MD, MEd, FHM, is a hospitalist, medical director, and vice chair of inpatient clinical affairs at the University of Cincinnati Medical Center in Cincinnati. He is also a member of The Hospitalist’s editorial board. Since reimbursement is the same regardless of length of stay, hospitals have a financial incentive to keep patients for shorter periods of time.

“The value of focusing on readmissions is to say, ‘Don’t just keep patients in the hospital for such a short amount of time that they will need to be readmitted within 30 days.’ I think this principle is sound, and hospitals have to weigh the length of stay and readmissions as a kind of balancing act,” he said.

“I think when you talk about what a hospital needs to do about readmissions, first get some baseline data. Do a needs assessment,” Dr. Mehta added. “Some gold standards are starting to emerge in the industry. They are important, but you really need to know what your own system is not doing well.”

The University of Cincinnati has a “meds to beds program because we don’t always know the patient’s medication purchase plan upon discharge. That’s one thing we do really well here. Another is follow-up care after discharge, which is emerging as another gold standard for the hospital industry. You want to be sure to make a primary care appointment within two weeks, which can be hard because of barriers to access to care,” he said.

Last July, the University of Cincinnati Health started an after-discharge clinic, which is a collaboration between hospital medicine and primary care. Located across the street from the hospital for patients who need it, the clinic assures inpatient clinicians that patients will get the follow-up they need. Another thing a lot of institutions are doing, with the help of their electronic health records, is looking more closely at high utilizers and flagging those patients most likely to be readmitted, who need to get more resources, more social work support, or more focus on medication reconciliation, Dr. Mehta said.

A readmissions committee

“Where I work, at a large inner-city hospital with all the issues that entails, when I look at our system, the highest rates of readmissions involve alcohol and substance abuse,” said Thejaswi Poonacha, MD, MBA, FACP, SFHM, a staff adult hospitalist, clinical associate professor of medicine and medical director for utilization management and clinical documentation integrity at the University of Minnesota Medical Center in Minneapolis, and a member of The Hospitalist’s editorial board.

Dr. Poonacha

“What we need to do is to see what can be done prior to discharge for these patients. We’ve tried to implement root cause analysis for frequent users at the time of discharge, to see if that root cause was something that could have been preventable.” At Dr. Poonacha’s institution, a licensed drug and alcohol counselor on staff works with the care management team.

“We use a software called Power BI, a Microsoft product, one of the major tools for looking at readmissions, along with data generated from the emergency departments and direct admissions. We have a readmissions committee that meets quarterly and sets goals for the year, led by a physician who generally has an administrative role in medicine in the hospital, and a nursing designate from administration.” This committee works with the multidisciplinary team, subject matter experts, and the care management team to put together an institution-wide plan, Dr. Poonacha said.

Pediatric issues are different

Issues surrounding readmissions are different for pediatric patients and for the hospitalists who manage their hospital care, said Anika Kumar, MD, FAAP, FHM, staff physician in the division of pediatric hospital medicine at Cleveland Clinic Children’s Hospital in Cleveland and The Hospitalist’s pediatric editor. Only a small percentage of these patients are covered by Medicare and its readmissions program, although private insurers are also concerned about covering preventable readmissions.

The vast majority of hospitalized children are discharged home with their parents, rather than to a rehabilitation facility, she said. “Our goal is to assure that when they are discharged home, the family is comfortable and fully trained in caring for them and has all the needed resources. Sometimes that requires a day of education in the hospital,” she said. For example, learning how to manage a nasogastric tube, or teaching with the actual medications on hand.

Dr. Kumar

“We are seeing more children with medical complexity, and I would say the patients who get readmitted are likely to be those with medical complexity, technology dependence, and/or comorbid chronic conditions,” Dr. Kumar said. “So our focus generally in peds is to address the children with medical complexity and ensure the resources for them to be safely cared for at home are accessible, such as home care.”

The majority of pediatric 30-day readmissions are not preventable, she said. An example is a child discharged with pneumonia who comes back in 29 days with a broken arm. And the data say that focusing on hospital readmissions in pediatrics does not produce measurable results.

What’s next?

“I will say that this problem of readmissions is not going away,” Dr. Duggirala concluded. “We’re improving our ability to treat patients, to reduce avoidable readmissions. The institutions that are doing it the best aren’t just focused on the six diagnoses included in HRRP. They’re creating pathways and processes that can be used for any discharged patient across the board.”

He is excited about the ways telemedicine has been shown to reduce readmissions, as confirmed in a 2021 study in the Journal of General Internal Medicine, and how it’s being integrated into transitional care via virtual visits.⁴ “As hospitalists, we haven’t yet entered the space of virtual transition clinics.” But that could be really important for a hospital like Wexner, where Dr. Duggirala practices, which serves a large catchment area two or three hours or more from the hospital.

“I’m excited for hospitalists and the opportunities for reducing readmissions in the future by leveraging our ability to step outside of our four walls and start focusing on how we can follow our patients [virtually] until we are able to give their primary care physician a warm handoff.”

Larry Beresford is an Oakland, Calif.-based freelance medical journalist.

References

1. Rau J. 10 Years of hospital readmissions Penalties. KFF website. https://www.kff.org/affordable-care-act/slide/10-years-of-hospital-readmissions-penalties/. Published November 4, 2021. Accessed March 6, 2025.
2. Uitvlugt EB, et al. Medication-related hospital readmissions within 30 days of discharge: prevalence, preventability, type of medication errors and risk factors. Front Pharmacol. 2021;12:567424. doi:10.3389/fphar.2021.567424.
3. Society of Hospital Medicine. SHM’s MARQUIS med rec collaborative. SHM website. https://www.hospitalmedicine.org/clinical-topics/medication-reconciliation/marquis-med-rec-collaborative. Accessed March 6, 2025.
4. Dawson NL, et al. Home telemonitoring to reduce readmission of high-risk patients: a modified intention-to-treat randomized clinical trial. J Gen Inter Med. 2021;36(11):3395-3401. doi:10.1007/s11606-020-06589-1.
5. Rau J. Medicare punishes 2,499 hospitals for high readmissions. KFF Health News website. https://kffhealthnews.org/news/article/hospital-readmission-rates-medicare-penalties/. Published October 28, 2021. Accessed March 6, 2025.