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Too Many Patients Are Re-Hospitalized
The process by which patients move from hospitals to other care settings is increasingly problematic, as hospitals shorten lengths of stay and as care becomes more fragmented. Medicare patients report greater dissatisfaction in discharge-related care than in any other aspect of care that CMS measures. The number of readmissions is alarmingly high.
- Within 30 days of discharge, 17.6% of Medicare beneficiaries are re-hospitalized; up to 76% of these readmissions may be preventable.
- Of Medicare beneficiaries who are readmitted within 30 days, 64% receive no post-acute care between discharge and readmission.
Reducing Hospital Readmissions
Health care utilization and hospital readmission rates vary among geographic locations. The most effective means for decreasing readmission rates nationally is to drill down to the processes of care at the community level and uncover opportunities for improvement in areas with higher observed rates. Therefore, Mountain-Pacific will form relationships with many community organizations and play a coordinating role to ensure community-wide adoption of improved practices.
Since local areas vary substantially in health care utilization, the most effective interventions may depend on changes in the processes of care at a community level that engage more than one provider (including hospitals, home health agencies, dialysis facilities, nursing homes, and physician offices), as well as patients, families, and community health care stakeholders.
More Resources for You
The National Coordinating Center (NCC) for Integrating Care for Populations and Communities assists Mountain-Pacific and other Medicare quality improvement organizations (QIOs) to promote seamless transitions between health care settings. For more information, visit the NCC's website.
Additional Links:
http://www.cfmc.org/integratingcare/learning_sessions.htm Recordings of past learning sessions about the Integrating Care for Populations and Communities AIM and other resources
http://www.cfmc.org/integratingcare/provider_resources.htm Provider Resources for the Integrating Care AIM
http://www.cfmc.org/integratingcare/patient_resources.htm Patient Resources
http://www.cfmc.org/integratingcare/toolkit.htm Tool kit
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