What are the best strategies for reducing hospital readmissions?

In my experience, reducing hospital readmission is a collective process involving everyone on the medical team, nursing team, and the patient's team. But first identifying which patients are at highest risk for readmission is paramount. Admission diagnoses, socioeconomic status, race, activity scores, involvement of family members, and even cognitive abilities play a factor in readmission risk assessment. When the whole team understands the process and communicates well, the patient is less likely to be readmitted as the discharge plan can be adjusted accordingly to needs.

Discharge planning process starts upon admission and identification of the admission diagnosis. The more complex the patient, the earlier the discharge planning team must become involved. The process is interdiscipliary consisting of medical providers, nurses, social work, therapists, patients, family members, and more. Most hospitals have protocol set in place to help ensure a seamless discharge process. Regardless of the process set into place, good communication is the catalyst. And it starts on the day of admission.

I agreed with you. Effective discharge planning is not an easy task. Takes time, you have to listen, you have to talk. It is important a ?? initial assessment, realistic planning, coolaboration, patient/family involvement, patient’s options, preferences, awareness of resources available in the community, communication and education ?? ect ect ect

Regardless of where a patient is discharged to - home, rehab facility, long term care facility, etc. - follow up is paramount and often the forgotten step. It is the weakest link. Hospital admissions are stressful on patients. But discharge is more stressful as the patient transitions from 24/7 care to either independence or minimal care. I work in primary care so I see patients for discharge follow up visits called "transitional care management." These are scheduled with the primary care provider by the hospital prior to patient discharge to ensure appropriate follow up care. I have found these visits to be very helpful as they have improved patient understanding of what to expect during recover.

Communication is a forgotten step in reducing hospital readmissions. Unfortunately, in this ever-advancing technological age, face to face communication is lacking. Broken communication can have detrimental effects on patients. I have seen patients in post-hospital discharge visits who were unaware of diagnoses they were admitted for. Some were unaware of medication prescriptions they were given upon discharge. And some were unaware of specialty follow up visits that had been scheduled for them. Ensuring proper closed loop communication is the best way to ensure patient understanding. Subsequently printing out clear discharge instructions and reviewing them with the patient is paramount. However, it starts with better team communication.

Utilization of digital technology for monitoring and follow up .Home visits are key in follow up and assessing the home environment the social support environment support plays a key role. Targeted patient education that is age and gender sensitive

A single readmission is not a failure. And to ensure no readmissions will by necessity have the duration of stay increased. It is more reasonable and overall efficient to accept a level of readmission. Personally I would predict that if the transmission rate is not 15-20% then patients are being kept longer than required in acute care facilities. In fact if you don't have a readmission rate, you are not at the boundary of modern care requirements. A prompt readmission path would be a better solution than embarrassing clinicians over readmission rates.