Discharge Planning to Reduce Hospital Readmissions

Address discharge barriers for the best patient outcomes

Patients typically get very excited when they hear “discharge.” Discharge means they are going home, but it also means patients will be caring for themselves once they get home. If patients don’t understand their care plan, or aren’t engaged in their plan, their chances of readmission after discharge increase.

Effective hospital discharge planning and post-discharge support are crucial for reducing readmissions. This involves providing clear, written discharge instructions, understandable medication information, facilitating timely follow-up appointments and calls, and connecting patients with necessary community resources. 

It may sound like a lot, but with a solid discharge solution, you’ll send your patients home equipped to engage in their care plan.

The readmission stats

Currently, 15% of patients covered by Medicare are readmitted to the hospital within 30 days of discharge, and 1 in 4 of these readmissions are potentially preventable.

Readmissions are estimated to cost $26 billion in the United States each year — a significant burden on the healthcare system. Unfortunately, a substantial portion of this burden falls on hospitals since readmissions are often not reimbursed fully, especially if they are due to preventable complications.

The Hospital Readmissions Reduction Program (HRRP) reduces CMS payments by up to 3% for hospitals over the national averages for readmissions for six specific conditions:

• Acute myocardial infarction (AMI)

• Chronic obstructive pulmonary disease (COPD)

• Congestive heart failure (CHF)

• Pneumonia

• Coronary artery bypass graft (CABG) surgery

• Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)

A staggering 82% of hospitals' payments were reduced for fiscal year 2019 under this program.

Factors contributing to readmission

A range of factors can contribute to hospital readmissions, but studies point to these issues as some of the leading causes:

Inadequate discharge education. Research has linked poor patient education to a 4.4% higher readmission rate. For the best results when teaching, use multiple methods — like written communication, drawings, or teach-back — to determine how best your patients learn new information. Also, provide reliable resources they can take home. The patient education materials from Patient Guide Solutions align with the most current recommendations from many leading healthcare societies.

Inadequate follow-up. Research shows that patients who had an early follow-up — within seven days of discharge — had a much lower risk of 30-day readmission. Another study showed that patients who received primary care follow-up within 30 days after discharge had a 67% adjusted reduced risk of 30-day readmission.

Medication errors. A fifth of all readmissions happen because of medication errors.

Individualized discharge plans

Discharge presents an important opportunity to create an individualized discharge plan. In 2023, a small quality improvement study of 33 patients in two teaching hospitals found that only one patient received counseling on six key discharge communication domains: medication changes, appointments, disease self-management, red flags to watch for, encouraging patient questions, and teach-back.

A recent meta-analysis of 17 studies found that patients who received individualized discharge planning had an 11% reduction in readmissions.

These studies show the overarching importance of individualized discharge, but this almost “personalized” approach is also crucial for patients with health conditions that make them more likely to be readmitted.

One condition warranting special focus is CHF. Not only is CHF part of the Hospital Readmission Reduction Program, but more than 30% of patients hospitalized for heart failure are rehospitalized or die within three months of being discharged.

This is where an individualized discharge plan helps, like integrating a cardiovascular checklist into the discharge planning for CHF patients. One hospital did precisely this. Research conducted at St. Joseph Mercy Oakland Hospital revealed that a heart failure discharge checklist reduced heart failure readmission from 20% to just 2%. The checklist consisted of 27 questions and ensured the patient had:

• Optimal fluid status

• Correct prescriptions

• Follow-up scheduled within seven days of discharge

Structured discharge plans

Structured discharge plans can follow established best practices and be individualized to the patient's needs. The RED (Re-Engineered Discharge) After Hospital Care Plan, developed by the Agency for Healthcare Research and Quality (AHRQ) and Boston University Medical Center, describes a structured discharge plan that can lead to a decrease in hospital readmission rates of 30%, studies say.

Elements of the RED After Hospital Care Plan include:

• Hospital discharge date, hospital contact information, and location

• Information on whom to contact with questions after discharge

• An updated medication list, including instructions for taking new medications and side effects

• A medication allergy list

• A list and calendar of upcoming appointments for the next 30 days

• A diagnosis information page

• A list of outstanding test results to expect

• A list of medical equipment the patient needs to obtain

• Advanced directives

• Diet recommendations

• Exercise and physical activity limitations

Multidisciplinary team approach

A multidisciplinary team model encourages clear communication between healthcare and social workers to help coordinate the patient's post-discharge needs. An interdisciplinary approach with a COPD care bundle helped one health system reduce COPD readmissions by 8%, suggesting a promising avenue to explore.

Engage family and caregivers

Involving family members in discharge planning has a significant impact on readmissions. A family member can help:

• Manage medications

• Manage diet

• Remind patients of physical restrictions

• Assist the patient in the activities of daily living

• Give patients rides to follow-up appointments

Post-discharge support

Post-discharge support can be through follow-up appointments, phone calls, or home visits. In one study, a 72-hour post-discharge follow-up call reduced 30-day psychiatric readmissions by 3.4%.

For certain conditions, setting up patients with an outpatient multidisciplinary program can help too. One heart failure-specific cardiac rehabilitation program reduced admissions to the hospital by 25% after discharge.

Conclusion

Effective discharge planning is critical in reducing hospital readmissions and improving patient outcomes. When optimizing your discharge process, be sure to address team communication, medication management, caregiver involvement, targeted education, and post-discharge follow-up. A proactive approach to discharge planning not only reduces the financial burden on your hospital, but also contributes to improved patient satisfaction and overall well-being.