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Thinking Seriously About Readmissions—and Care Transitions

September 4, 2012
by Mark Hagland
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A new report by CSC’s Jane Metzger offers insights on the challenges facing hospital leaders in averting readmissions going forward

In August, the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices, a division of the Falls Church, Va.-based CSC, released a white paper entitled “Preventing Hospital Readmissions: The First Test Case for Continuity of Care.” That white paper, authored by Jane Metzger, principal research in the Global Institute, looks at a variety of factors that might help hospitals to reduce avoidable readmissions, in the context of the healthcare reform-driven mandate to do so, under the Affordable Care Act (ACA).

As Metzger notes in the introduction to the white paper, “Hospital readmissions were one of the earliest targets of both quality measurement and performance-based incentives for Medicare and other insurance programs,” partly because a great deal of information is easily available through claims data that can help payers (both public and private) to target issues in hospitals that might be behind readmission levels. It’s not surprising, then, of course, that avoidable readmissions work became a mandatory element of the ACA for all hospitals receiving Medicare payment.

What Metzger finds in her review of the literature is that averting the readmission of high-risk patients—primarily those defined as having heart failure, pneumonia, or an acute myocardial infarction (AMI)—“is very challenging, because so many community and patient factors contribute to the problem, many of them outside of the direct control of the hospital. However,” she adds in the white paper, “research, combined with practices in hospitals with a track record of reducing readmission, shows that comprehensive discharge planning and post-discharge care and support during the transition period reduces readmissions in high-risk patients.”

CMS, Metzger notes, has targeted four key outcomes measures, in the context of the mandatory readmissions reduction program under Medicare: 30-day risk-standardized readmission rates for AMI, heart failure, and pneumonia, and the 30-day risk-standardized readmission rate for all conditions.

In figure 1 below are the “Common process breakdowns associated with potentially preventable readmissions”:

Figure 1

Common Process Breakdowns Associated with Potentially Preventable Readmissions

Care Gaps During Stay

  • Patient safety (especially medication- and infection-related)
  • Medication reconciliation not completed or inaccurate at admission or discharge

Patient Factors

  • Lack of understanding of post-discharge plan of care
  • Lack of understanding of what to watch for (warning signs), how to respond
  • Non-compliance with any or all elements of post-discharge self-management and care
  • Lack of Timely Post-Discharge Care
  • No appointments available or no relationship with a primary care provider
  • Logistics, such as no transportation
  • Primary care physician unaware of hospitalization


  • Delayed, lacking or inadequate communication with next provider or direct care
  • Lacking or inadequate communication with home care provider (including family)

Such issues are going to become increasingly prominent in the near future, industry observers agree. Indeed, in releasing details of the program on Aug. 1, the Centers for Medicare & Medicaid Services (CMS) revealed that more than 2,200 hospitals, or two-thirds of U.S. hospital organizations, will see payment of reductions of up to 1 percent within the next year.

Jane Metzger spoke recently with HCI Editor-in-Chief Mark Hagland about her findings, and about their implication for healthcare and healthcare IT leaders. Below are excerpts from that interview.

The mandate for significantly reducing avoidable readmissions has really become an immediate challenge for hospitals, hasn’t it?

Yes, and hospital leaders are going to have to take the lead on it, because it’s here and now for them. Now, over time, the role of hospitals in transitional care will decline somewhat. But I think they’ve got a big problem today, because of the kinds of collaboration required, the continuity of information, and really having to do it all is a huge challenge.

Jane Metzger

What are the biggest challenges right now for hospital leaders in this area?

Well, I think the approach to readmissions in many hospitals has been somewhat narrowly focused. For example, a lot of programs you read about will be only for congestive heart failure (CHF) patients. And it is true that what programs look like will be different for different conditions. So I think that one big challenge for hospitals is that they’re going to have to think more about this process of transitional care and support, across larger numbers of patients. In other words, it’s no longer the CHF program. But I think that what they’ve been doing for CHF patients, except for the condition-specific elements, is a model for what they’re going to have to do for many patients. And though they’re going to have to do the same kinds of things for high-risk patients, what I’m arguing in the care plan is that I think there’s going to have to be a transitional care plan for all patients. And it may be simple to begin with.