To reduce unnecessary hospital readmissions, experts suggest a combination of discharge planning, coordination among providers, and intensive counseling for patients. For many underresourced U.S. hospitals, however, it may be difficult to commit to such a rigorous care transition program for all patients. This Commonwealth Fund–supported study tests the theory that applying such programs only to those patients most at risk for rehospitalization may be a more effective strategy.
What the Study Found
The researchers identified hospitalized heart failure patients who were the most likely to be readmitted within 30 days by using a risk-prediction model based on 29 clinical, social, behavioral, and utilization factors in patients’ electronic medical records. These patients were targeted for an intensive set of counseling and monitoring activities, including detailed education and discharge planning, follow-up telephone calls, outpatient case management, and primary care and specialist follow-up appointments.
After the intervention, the overall 30-day readmission rate for heart failure patients fell from 26 percent to 21 percent. There was no significant change in readmission rates for patients with pneumonia or acute myocardial infarction, who were not included in the intervention.
Directing largely existing resources to a smaller subgroup of hospital patients based on their higher risk level produced a meaningful reduction in overall readmissions.