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Hospitals in Medicare project blame communication gaps for readmissions

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Reduce readmissions with a simple discharge communication tool for care teams

By Laurie Robinson, RN, Director of Louisiana CMS Care Transitions Project

It’s a daunting number that is a poor reflection of health care quality; 64%. This is the percentage of Medicare beneficiaries who return to the hospital within 30 days without having received any post-acute care following their discharge. A large number of these patients are “high risk,” with complex, acute conditions and end stage diseases. Yet, they were not referred to home health or hospice care. Why aren’t we sending these patients home with the necessary resources?

One reason is the medical record does not include an easy-to-read summary of the patient’s crucial needs, both clinical and social. Without this, it is unrealistic to expect a good outcome when the individual is discharged to home.

Case managers need to understand the challenges facing the patient in the home environment as well as clinical data. For example, knowing that a patient has co-morbidities such as diabetes and COPD is important in the after-care plan, but understanding their lack of family support in the home would also create a trigger for considering a home health referral.

eQHealth Solutions collaborated with case managers and nurses to develop a simple tool that helps discharge planners better understand the complete needs of the patient and prevent a readmission even before the patient is discharged.

 Use this communication tool to help reduce readmissions by:

• Providing your discharge planning teams with clear guidance for when to refer patients to home health or hospice care. Case managers use the simple risk factor checklist to calculate a patient’s risk score and make recommendations to home health or hospice services based on the patient’s score and the eligibility criteria listed on the tool.

The tool works by:

• Creating a common process for evaluating patients’ risk and determining the appropriate post-discharge care. Discharge planning teams make an accurate assessment of a patient’s health status and post-discharge needs using the tool because it creates a complete information source to identify all of the patient’s risk factors and the appropriate resources.

• Improving proactive communication of post-discharge recommendations to the physician. Case managers use the tool to determine the patient’s risk level two days before discharge. This enables the discharge planning team to make care recommendations before the physician has already decided on the patient’s post-discharge plan.

Reduce readmissions by closing knowledge gaps in discharge planning

Hospitals across the country have prevented readmissions by filling patient knowledge gaps with education and health coaches. But patients aren’t the only ones lacking critical information. Case managers and treatment teams today are forced to use inadequate information about patient risks and available resources to make care decisions that result in readmissions.

This new discharge tool tackles causes of readmissions from the hospital perspective. Hospitals using this tool as part of a CMS project saw a statistically significant increase in their referrals to home health and hospice, as well as reduced readmissions.


Laurie Robinson, RN, Care Transitions Project Director, explains how to use this tool:


Additional resources and tools for reducing readmissions:

Download the free discharge risk assessment tool here.

Use this patient discharge checklist to reduce readmissions in your hospital.

Hear from one hospital physician who used buzz-words to reduce readmissions.


Permanent link to this article: http://www.eqhssmarterhealthcare.org/hospitals-in-medicare-project-blame-communication-gaps-for-readmissions/


  1. Gail

    I am employed by a Home Health Agency. Since we began the mandatory Face to Face for admissions, we have heard physicians complain about “more paper work and another form to fill out and sign. Maybe we’ll just stop referring to Home Health and Hospice.” We have noticed that our referrals (as have other home health agencies) are down lately. Recently a friend’s mother was sent home after a week long stay in ICU with heart related problems with instructions for “comfort measures” because there was nothing else her cardiologist could offer…no Home Health or Hospice referral. When physicians start feeling the pinch in their pocketbooks when the patient they just discharged is readmitted to the hospital within 30 days, maybe they’ll get the picture.

  2. Laurie Robinson, RN

    Thanks for your comment Gail.

    Working with discharge planners who have faced these same barriers, I understand how frustrating it can be. We heard from physicians in our project that they saw outpatient services, such as home health, as best managed by the PCP who is more intricately involved in the patient’s care. The cardiologist, for example, may not think it’s appropriate to make a treatment decision for a health issue that is unrelated to the patient’s heart failure.

    We did find that identifying post-discharge care needs early on helped improve referrals. It gives the physician time to make recommendations to the PCP. It also gives the PCP time to assess the patient’s needs before ordering services.

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