Best Practices for Preventing Re-hospitalization

“Hospitalizations account for nearly one-third of the total $2 trillion spent on health care in the United States.”[1] A significant fraction of these hospitalizations are re-hospitalizations occurring soon after discharge. Re-hospitalizations result in increased costs to the payer, and potential negative impacts on patients related to complications of being hospitalized. The most important point here is that these re-hospitalizations can often be avoided.

Back in 1992 when I started my first job in home care things were a lot different. We were reimbursed by the visit so it was a common practice to visit our patients often. We did not have cell phones or laptops. No, we did not have horses and buggies either, but we did have pagers. Communication was more difficult, relying on patient phones and phone booths to contact the office.

If someone mentioned the word “Oasis” we would have pictured an isolated, sunny, warm location with a spring of fresh water and wondered what that had to do with home care. There was no Quality Improvement Organization (QIO) to go to for help and no one knew what their clinical outcomes were. You did not know what your Acute Care Hospitalization (ACH) rate was and you certainly could not compare your ACH rate to the state or national average. Wow, a lot has changed.

Some of the challenges we faced keeping patients out of the hospital then still exist today, but are finally beginning to be recognized and addressed. For instance, at discharge, patients were, and still are, handed a piece of paper called “Discharge Instructions” and bid farewell at the hospital door. Rarely had they actually been instructed during their hospital say on how to care for themselves after discharge. They went home not knowing how to check their blood sugar, care for their incision, or when to take their medications.

Another problem was that the list of medications on the discharge instructions rarely reflected an awareness of the medications the patient was taking before they were hospitalized, which were still available in the home, causing confusion for patients and family members. It took a homecare nurse days and many phone calls to figure out the correct, safe medication list because the primary care physician never knew what medication changes were made in the hospital. No system was in place to deliver a report from the hospital nurse to the primary care physician. Worse, patients were often sent home before the home care referral was made and without the equipment they needed. We complained about the problems with the process, we met with hospital officials, but we never saw the changes that were needed.

Looking from the outside in it was easy to see why re-hospitalization rates were so high. Correcting it would not be as easy and would require coordination between home care and hospital nurses. In the beginning of the initiative to decrease re-hospitalization rates, it was left to homecare agencies working with the state QIO to bring ACH rates down. That approach was marginally successful but real progress could not be made by home care agencies alone. Hospitals and nursing homes, however, had no incentive to work with home care agencies to impact these high re-hospitalization rates.

Today, thanks to financial penalties for readmission’s within 30 days for certain diagnoses, hospitals now have the incentive to actively assist us with this effort. We are very fortunate to have the resources, tools, and support of CMS and the industry in tackling this issue and decreasing avoidable re-hospitalizations.

If I could travel back in time and tell the clinicians and administrators I worked with back in the 1990s what we have today, it would be funny to see and hear their reactions. I can even picture it in my head. Would they think I was a visionary or just plain crazy? As I said, much has changed.

Resources and Tools Available

As you begin your effort to reduce avoidable hospitalizations, there is no need to reinvent the wheel. There are many tools available, so all you need to do is review all of them and decide which would work best for you. There are basic core best practices that should be followed but the technique you chose is up to you.

I see it like shopping for clothes. You could make your own clothes if you wanted to and had the time but you do not need to; simply shop for the clothes that best fit you and your needs. After meeting your basic needs like underwear, socks and pants you can customize your own style and preferred fit. I would recommend that you perform an internet search on “best practices for preventing re-hospitalizations” and identify the approaches that are right for you. I will review just a couple here so you get the idea of some of the resources available.

The Institute for Healthcare Improvement (IHI) implemented a plan called “State Action on Avoidable Re-hospitalizations Initiative” (STAAR). STAAR focuses on reducing re-hospitalizations by working across organizational boundaries to improve the delivery of effective care. This is a critical component that was missing in my early days in home care, working together with other care organizations. It is nice to see that we are finally working on this issue as a whole and understanding the big picture. Two areas that the STAAR initiative is focused on are improving transitions of care and engaging state-level leadership to understand and mitigate systemic barriers to change.

Looking back on the obstacles we faced in the 90s, these were two of the top challenges. I am grateful that the IHI identified these as target areas on which to focus their efforts. One of the tools on this site that caught my eye was entitled “How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Re-hospitalizations.” This guide is designed to support home health care teams and their hospital and community stakeholders, in working together to design and implement improved care processes to ensure a smooth transition from inpatient setting to home health care during the first 48 hours following discharge.

One of my favorite sites is the Home Health Quality Improvement (HHQI) website at On this site you can find basic, what I call core, best practices for reducing re-hospitalization rates. I am referring to best practices such as:

  • Hospital risk assessment tools
  • Emergency care plans
  • Call me first posters
  • Fall risk assessments
  • Medication management tools, etc.

In addition to the basics, you can also find best practices and tools for patient coaching and teach back methods, phone monitoring and assessment programs, and disease management tools just to name a few. I am really glad that there are so many free resources and tools available to help the home care industry implement best practices and improve the care we deliver to the most important people, our patients. I encourage you to use them.

Regardless of the resources, tools and support available it is impossible to decrease your agency’s re-hospitalization rate unless you focus on it, take action, and make it a priority. This involves identifying what your re-hospitalization rate is now and how you compare to other agencies in your region, state, and the nation. It also involves action on your part to implement some of the best practice strategies and tools provided, and monitor for progress. Take an action step today! It will be well worth it.

[1] “State Action on Avoidable Rehospitalizations (STAAR) Initiative”, access on 10/24/2014, last modified 10/19/2014.

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