Home Care Heroes Blog

8 Steps You Can Take to Prevent Avoidable Readmissions

Hospital profit margins are increasingly at risk, and as the Hospital Readmission Reduction Program continues to expand under the Affordable Care Act, hospital administrators are really feeling the heat. In a terrific article in Becker’s Hospital Review, eight strategies to reduce readmissions are highlighted:

 1.) Manage care transitions effectively. Did you know that the number one cause of medical errors in the U.S. is the poor transition of clinical care? Not only do these errors harm patients, but they also account for $25-40 billion each year in excess care costs.

  • I_Heart_Accountability_T-ShirtAccountability.  When all care transitions include medical records that meet certain minimum standards, accountability is greatly enhanced.
  • Care Coordination and Family Involvement. Care coordination best occurs via a provider who serves as the “hub” of care.
  • Communication. Timely communication during changes in health status is one of the many keys to managing care transitions.
  • Adherence to National Standards. Care quality is markedly improved when standards of continuous quality measurement and improvement are put in place.
 2.) Employ IT effectively, including clinical decision support. During any hospital admission, use of clinical practice guidelines is known to improve clinical outcome.

 3.) Stratify readmission risk for each patient. How various patient factors like multiple chronic conditions, poor patient education prior to discharge or the presence of adverse drug effects related to certain high-risk medications must be considered in the readmission risk profile for each patient.

 4.) Employ a transition coach or discharge advocate. The importance of the role a transition care coach cannot be emphasized enough in contributing to the success of a readmission prevention program.

  1. 5.) Consider using telemedicine, especially for the sickest patients. Telemetric monitoring is an attractive strategy to alert physicians of changing health status.

 6.) Affiliate with a patient-centered medical home. Research suggests that patient-centered medical homes can decrease the cost of providing care to groups of patients by as much as five percent.


 7.) Educate patients about readmission risk. Standardized discharge instructions for the highest risk categories are routinely available and effective.

8.) Devise a formal plan to communicate a final checklist before discharge.  A clear and comprehensive care transition plan can greatly reduce any confusion the patient may have about his or her continued treatment plan.

These eight guidelines for preventing avoidable hospital readmissions present great opportunities for hospitals, doctors and care transition agencies to alter existing care structures in ways that have minimum impacts to the system and at the same time provide maximum positive impact for the patients.

To learn more about running a care transitions program and about Ankota's care transition software, press the button below:

Click to Learn how to Increase Profit via Care Transitions

Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Reeadmisison avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact Ankota.

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