By:  Shay Jacobson, RN MA NMG LNCC CNLCP

Martha Kern

It is by now fairly well understood that Medicare means business where hospital readmissions are concerned. The endeavor to prevent hospitalizations, in general, and hospital readmissions, in particular, is part of the Affordable Care Act and one that is already paying dividends. Meticulous scrutiny of patient status, medical necessity and factors driving readmission has resulted in millions of dollars saved by Medicare.

The path to cost savings has not, however, been painless. The current focus on admissions/ readmissions has shifted costs to patients as they struggle to understand how a stay in the hospital is merely “observation” and an outpatient Medicare B service. The medical community, too, has had some difficult adjustments, undergoing ongoing and incessant auditing by Medicare and learning the rather complex realm of medical necessity as it applies to inpatient versus observation status and the Two-Midnight Rule (otherwise known as the Pumpkin Rule). Doctors must prognosticate, document and defend their positions where patient status is concerned.

All of these changes are frequently discussed on a metric basis. We hear a great deal about the percentages where readmissions are concerned and the number of midnights required to qualify for post-acute care. We hear somewhat less, it seems, about who is being readmitted, why they are being readmitted, and how we might prevent this cycle from reoccurring.

The “Flagged” Diagnoses

Medicare has, understandably, focused much of its attention on the diagnoses that seem to trigger the greatest number of readmissions, and thus cost them the most. These diagnoses include:

  • Congestive Heart Failure
  • Acute Myocardial Infarction (heart attack)
  • Pneumonia
  • Chronic Obstructive Pulmonary Disease (COPD)
  •  Recent studies of chronic disease and readmission rates also suggest the following diagnoses increase the likelihood of readmission:
  •  Depression
  • Asthma
  • Diabetes

As patients come into the hospital with these diagnoses, service providers and insurers can “flag” them and execute special protocols to better manage their discharges. It has been argued, however, that the hospital’s Locus of Control is somewhat limited as patients depart that supervised environment, and centers chiefly on the following spheres of improvement:

  • More effective discharge planning
  • Prevention of premature discharges
  • Quality of inpatient care improvements
  • Improved coordination of care between inpatient and outpatient providers

It has further been emphasized by health care service providers that a patient who is readmitted on day 29 post discharge should not be categorized in the same way as the patient who is readmitted within hours or a few days of discharge. This latter scenario is certainly suggestive of some kind of lapse in the hospital care and/or discharge process (i.e. premature discharge or substandard care coordination). The former scenario may or may not have anything to do with the initial interval of care. There may be a host of other causes/factors when it comes to the patient who readmits 28, 29 or 30 days after discharge.

What Increases the Risk of Readmission?

Apart from the known high-risk diagnoses on which Medicare is already focused, there are a number of other factors identified by the Society of Hospital Medicine that seem to ratchet up the probability of hospital readmissions. Many of these fall outside the hospital’s Locus of Control.

These are known as the “8 P’s”:

Problem Medications

Certain medications appear to trigger a disproportionate number of adverse events after discharge. The list is long and features, among others, the following medications: warfarin, insulin, digoxin, and aspirin when used in combination with Plavix. It is not yet known if these medications lead to higher risk in patients just starting them or in the entire user population.


Patients with a history of depression demonstrate a higher likelihood of re-hospitalization. Those who have not been formally diagnosed but who exhibit depressive symptoms should also be watched more closely upon discharge.

Principal Diagnosis

Adverse post-discharge events are also linked with patients whose primary reason for hospitalization (principal diagnosis) is included on this list: Cancer, stroke, diabetes or glycemic complication, COPD, and heart failure.


Evidence indicates that patients who use five or more medications (scheduled, not as needed) are not only at increased risk for post-discharge complications, but also for decreased compliance.

Poor Health Literacy

The teach-back method is recommended as an effective means of identifying discharging patients with poor health literacy, enabling clinicians to immediately correct misunderstandings.

Patient Support

A lack of good social support in the community seems to have a negative effect on older patients, in particular, as they discharge. Whether the caregiver arrangement is formal or informal, the absence thereof is associated with higher re-admissions.

Prior Hospitalizations in the Last Six Months

The single most predictive risk factor for future hospitalizations is past hospitalizations. The existence of unplanned hospitalizations in the six months prior to the current episode is a strong indicator of re-admission risk. As has been said in other contexts, past behavior is the best predictor of future behavior, and the same is true for unforeseen hospitalizations.

Palliative Care

Of the patients who qualify for palliative care, only a small percentage receive it. Palliative care improves symptom management and patient satisfaction, and also reduces the use of resources (inclusive of re-admissions) as patients near the end of life.

The Most Effective Intervention: Care Coordination

It comes as no surprise to those of us who serve clients in the community that the availability of consistent, formal care coordination is the single most significant intervention in the reduction of re-admissions. The presence of one or more people who know the patient and the patient’s history, and who are available to make arrangements and ensure compliance with follow-up care recommendations and prescription drug use, changes the equation substantially.

Harking back to the era of the family doctor (think Marcus Welby) who has a long history with a patient, and the era of the home-based female head of household who cared for young and old alike, the introduction of solid care coordination revives a model wherein one or two people are intimately familiar with all facets of a case and can make sure various disciplines and specialties are not operating without knowledge of the others’ actions. The Affordable Care Act’s “Medical home model” seeks to replicate this same idea where, despite the involvement of multiple practitioners, there is one overseer (the primary care physician) who has a panoramic view of the case.

Absent the ability to personally and physically offer a patient post-discharge care coordination services, there are other “low-touch” methods that may have a similar impact in precluding hospital bounce backs. These include:

Telephonic checks – Ambulatory surgical centers have used this technique for years and likely head off myriad complications with a simple call to the patient the day after discharge to see how they are feeling. Patients may well report pain, bleeding or other signs of potential trouble to a professional who calls them more readily than they would pick up the phone to initiate that interaction themselves.

Carrying out one home visit – High risk patients may benefit immensely from one follow-up home visit during which a professional health care provider can assess the environment, medication management and compliance, and other factors that could undermine patient compliance and/or welfare.

Eyes and Ears in the Outside World

Community-based providers have a clear advantage in their ability to assess and offer interventions when high-risk patients leave the hospital. They can take clients to follow-up medical visits, reconcile medications, evaluate and modify the environment and otherwise improve a patient’s chance of identifying issues early and avoiding re-hospitalization.

A private care manager serves in this role and represents an amalgam of Marcus Welby (a family doctor with long-term patient relationships) and the absent female head of household who was once available to care for family members at home.

Here are a few examples of the kinds of situations in which a private care manager can identify and remediate a problem before it triggers hospital re-admission:

• Follow up with “outliers”, meaning those patients whose hospital stays have featured multiple complications and who stayed in the hospital longer than initially anticipated;

• Situations wherein cognitive impairment may hamper a patient’s ability to comprehend and follow discharge instructions, and who lack a Power of Attorney and/or Guardian;

• Support for patients who are entangled in difficult family dynamics where estrangements and feuds impede and complicate follow-up care;

• Relief for elderly patients who are themselves caregivers for adult disabled children who continue to live with them and rely on them;

• Intervention in situations where exploitation or abuse is suspected or known, whether financial, emotional or in the form of withheld services;

• Assessment and remediation in situations where hoarding or other environmental factors compromise patient safety, wellbeing and recovery.

The 9th “P” – Pandemonium

The situations outlined above are just a few examples of the kinds of problems that can have a potent effect on a client’s discharge and successful recovery outside the hospital. Community-based partners can recognize and intervene in chaotic situations much more readily simply because they have access to the home environment and the rest of the family, and are involved with a client over time.

An unstable or abusive home environment or even one wherein a client’s care needs are not recognized and met, can increase the likelihood of a hospital readmission. Cases like these demonstrate the positive impact of community-based care management on circumstances where a client was poorly supported and could easily have continued in a negative spiral with repeated hospitalizations:

• A 55-year-old woman, contending with a personality disorder, was hospitalized twelve times in the course of a single year. Care management and careful coordination of the client’s care over the past eight years has stabilized the client and all but stopped her hospital-to-home-to-hospital cycle. In eight years’ time, she has been hospitalized only twice.

• An elderly couple who cared for their adult disabled son in the home made a fairly effective care team until they aged and began to experience medical setbacks. The father died. The mother struggled to care for herself and her son, and hired Lifecare Innovations to assist her and to facilitate a plan for her disabled son. When she died a few years later, we became his guardian, just as she planned for us to do.

• An older woman lived with and financially supported her adult son in the community. She exhibited worsening signs of dementia and was known to act out, sometimes requiring interventions by law enforcement. She was repeatedly hospitalized. The hospital required that the son, who was reluctant to use his mother’s funds to pay for her care, prove that he had hired a caregiver to support her. He refused. The hospital petitioned for us to become guardian to get the client the care she needed and end the re-admission cycle.

Community-Based Transition Programs

In April, 2011, The Center for Medicare and Medicaid Services announced funding opportunities for acute-care hospitals with high readmission rates that partner with community-based organizations to improve a patient’s transition from hospital to another setting, such as a long-term care facility or the patient’s home.

The goals and parameters of the program include:

• Care transition services that begin no later than 24 hours prior to discharge;

• Timely and culturally and linguistically competent post-discharge education to patients so they understand potential additional health problems or a deteriorating condition;

• Timely interactions between patients and post-acute and outpatient providers;

• Patient-centered self-management support and information specific to the beneficiary’s condition; and,

• A comprehensive medication review and management, including—if appropriate—counseling and self-management support).

A budget of $500 million has been allotted for the program over a span of four years (2011-2015). Participants enter into two-year agreements and are paid an all-inclusive rate per discharge (akin to the bundled payment model being piloted in hospitals). Participants in Illinois include Catholic Charities, Age Options and the Council on Jewish Elderly.

The success of this program may well result in a more formal endorsement of community-based care management as a leading solution to the readmission problem. Care coordination and post-discharge follow-up are clearly vital and proven interventions, and patients at high risk for readmission will benefit from the expertise of licensed, clinical professionals who stay with them as they transition out of the hospital environment.

©Lifecare Innovations, Inc.