Readmissions Summary:

 What Are They?

"Readmission" occurs when patients who have had a recent stay in the hospital go back into a hospital again. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason. Often referred to as "rehospitalization."

Who's At Risk?

Patients in transition - those moving from one care setting to another - are at increased risk for hospital readmission.  Unanswered questions including  the following, can increase patient risk for readmission: who is in charge of the patient transition, what is the plan, whether the plan and follow-up instructions are understood, and knowledge of whom to call with questions once they are home or in their new care setting.

What's At Stake?

Patients move from one setting of care to another or to one set of care providers to another during an episode of illness. As patients and families navigate across new care settings and among different care providers, they often encounter communication challenges and confusion around who is clearly accountable for their care. This can lead to medical errors, duplication, increased costs and may also lead to higher rates of hospitalization.

What Providers Are Doing to Prevent Readmissions?

Massachusetts is currently participating in many projects to address and improve hospital readmission issues.  These efforts are largely coordinated state-wide by the Massachusetts Care Transitions Forum, and a list of these projects follows.

  • Re-Engineered Discharge (RED) Toolkit from AHRQ
  • Potentially Preventable Readmissions (PPR) Project with 3-M
  • STAAR Initiative:  STate Action on Avoidable Rehospitalizations
  • Interventions to Reduce Acute Care Transfers (INTERACT-II) Initiative
  • MOLST Demonstration Project:  Medical Orders for Life-Sustaining Treatment
  • Project RED (Re-Engineered Discharge)
  • Project BOOST (Better Outcomes for Older Adults through Safe Transitions)
  • Home Care Projects:  Masspro Collaborative Project
  • Business-led Projects:  Dovetail Health's Pharmacist-Led Transition Services to Avoid Costly Readmissions

3M Heath Information Services Potentially Preventable Readmission (PPR) Reports Webinar

In 2013, MHA's Board of Trustees challenged acute care hospitals to reduce readmission rates by 20 percent over the next three years.  To track progress toward that goal, MHA contracted with 3M PPR Classification System. 3M recently provided MHA with a statewide acute care hospital 30-day risk-adjusted PPR rate and analysis for FY 2012 to use as the baseline readmission measure. The analysis employed the Massachusetts acute care hospital discharge database obtained from the Center for Health Information and Analysis.
The contract with 3M also called for the production of hospital-specific PPR data reports to inform each hospital about their readmission profile and provide insights that may assist them with their readmission reduction efforts. Those reports were distributed by e-mail to acute care hospital CEOs on May 30 2014, A recording of the July 8, 2014 webinar explaining the PPR methodology and review the content of the hospital-specific reports can be found here.

Hospital Guide to Reducing  Medicaid Readmissions

A guide to help acute care facilities expand their current Medicaid readmission efforts is now available from AHRQ.

The new resource, titled Hospital Guide to Reducing Medicaid Readmissions, can help acute care facilities accomplish the following:

  • Adapt or expand existing Medicaid readmission reduction efforts. It helps identify readmission risks, transitional care needs, and adapt best practices from proven strategies like AHRQ's Re-Engineered Discharge, the Institute for Healthcare Improvement's State Action on Avoidable Readmissions, and the Society of Hospital Medicine's Better Outcomes for Older Adults Safe Transitions to serve the transitional care requirements of Medicaid patients.
  • Develop your Medicaid reduction strategy using the guide's roadmap featuring 13 customizable online tools. The tools can be downloaded individually here.
    Comply with CMS' Conditions of Participation requirements for a standard, improved, and transitional care for all patients. National, state, and local data show high rates of non-obstetric Medicaid readmissions.
  • Develop partnerships across other settings of the healthcare continuum. The tool helps create an inventory of resources and processes to aid building multidisciplinary teams with organizations and facilities offering post-hospital Medicaid transitional services.

The guide is the only federal tool available tailored for the adult Medicaid population. Hospitals at different stages of readmission reduction work can benefit from implementing this guide.

Six Strategies Hospitals Can Use to Reduce Their Readmission Rates

While there have been dozens of campaigns launched to help hospitals reduce their patient readmission rates, not much evidence exists to show which strategies are most effective.

In a study in Circulation: Cardiovascular Quality and Outcomes (July 2013 6(4):444-50) click here focused on heart failure patients, Yale University researcher Elizabeth Bradley and colleagues sought to find out which methods seem to have the greatest association with significantly lower 30-day readmission rates. The investigation, which drew from a survey of hospitals participating in national quality campaigns, yielded six effective strategies-only a few of which have been implemented by more than a third of the hospitals.

Visit to find out what they are.

A Gatefold Publication You Can Use 

One of MHA's Strategic Performance Improvement Priorities - reducing preventable readmissions - is garnering great attention in 2011. Hospital Boards of Trustees throughout Massachusetts are signing on to the three-part improvement initiative in which they pledge to address the issues of readmissions, mortality, and central line-associated bloodstream infections at their regular meetings; to advocate for healthcare policies that reduce incidences of the three issues; and to measure improvements in the three areas.

In February 2011, nearly 400 caregivers attended a two-day STAAR conference - or State Action on Avoidable Readmissions. STAAR is focused on improving care transitions to reduce readmissions. Twenty-two cross-continuum teams have been part of the STAAR project since September 2009, and 27 new teams came to the event to learn from their colleagues and begin their own work.

On the state and federal level, Medicaid and Medicare are, or are about to, institute penalties for excessive readmissions.

Now, Hospitals & Health Networks, the flagship publication of the American Hospital Association has produced this "Gatefold" publication on the readmissions issue. It lays out the numbers, key aspects of the Affordable Care Act relating to readmissions, the top seven hospital readmissions, and a checklist that STAAR states, such as Massachusetts, use to assess and remedy the problem.

Reducing Readmissions: Highlights/Specific Tools from Massachusetts STAAR Cross-Continuum Teams

For the past three years, the Massachusetts Hospital Association (MHA) and the Massachusetts Coalition for the Prevention of Medical Errors (the Coalition) have been working with partner organizations and with cross- continuum teams to reduce avoidable readmissions within Massachusetts and improve care transitions for patients and families.

Download Highlights and Specific Tools from Massachusetts STAAR Cross-Continuum Teams

HRET Action Guide to Reduce Avoidable Readmissions

Reducing avoidable hospital readmissions is an opportunity to improve quality and reduce costs in the health care system. This guide is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions.

Download HRET Action Guide 

 State Plan for Care Transitions

Under the auspices of the Massachusetts Statewide Quality Improvement Initiative (SQII), a task force developed a State Plan for Care Transitions. It is designed to be a useful tool for the Massachusetts healthcare community to realize a vision of integrated, high-quality, coordinated, and efficient health care delivery.

Healthcare Quality/Readmissions Issues Brief

Massachusetts is currently participating in many projects to address and improve hospital readmission issues. A summary of these projects follows.

Read More (PDF) »

STate Action on Avoidable Rehospitalizations Initiative (STAAR)

A multi-state project involving 53 hospitals, STARR was launched by the Institute of Healthcare Improvement (IHI) in May 2009 with grant funding from The Commonwealth Fund. 22 Massachusetts hospitals are enrolled in the initiative. To date, participating hospitals have formed cross-continuum teams and submitted baseline 30-day readmission rates. Now they are busy determining how to improve the patient's transition from hospital to post-acute setting.

Read More »

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