One in five Medicare patients hospitalized in the United States is readmitted within 30 days of discharge [1, 2] and 34% are readmitted within 90 days [16]. Seventy-five per- cent of those rehospitalizations were likely avoidable [2]. “Readmission” is defined by the Centers for Medicare & Medicaid Services (CMS) as hospitalization within 30 days of discharge from a prior acute care admission to a hospital [17]. Cost secondary to readmission is $17 billion for Medicare alone [16].

Poorly executed care transitions nega- tively affect patients’ health, well-being, and family resources, unnecessarily increase health-care system costs (IHI [5]), and raise the probability of readmission [14–16]. Medicare reimbursement penalties have been instituted by the Patient Protection and Affordable Care Act for hospitals with high levels of readmissions in recent years, making the topic of readmissions timely and valuable [2].

Policymakers and providers recognize that avoiding rehospitalizations improves quality of care and reduces health-care costs. Readmissions can be reduced by developing a system that is anticipatory rather than reactionary.

Transitions of Care Defined

Transitions of care is defined as the set of actions taken to ensure coordination and continuity of health care as patients are transferred among various care settings [3]. Transitions

of care, when done well, take the patient’s safety, goals, and well-being into account. High-quality transitions reduce the use of resources by decreasing emergency room utilization and the need for rehospitalization, decreasing cost to the health-care system, and increasing patient, family, and pro- vider satisfaction.

As an example, consider a frail 70-year-old female with congestive heart failure who is admitted to the hospital for a hip fracture. If she tolerates the procedure, does not have postoperative complications, and stabilizes medically, her care will be transitioned to a skilled nursing facility (SNF) for rehabilitation.

Once at the SNF, if she decompensates medically and becomes delirious or has an exacerbation of her congestive heart failure, she will likely be sent back to the emergency room and probably readmitted to the hospital. However, if her rehabilitation at the SNF progresses well without medical complications, she will successfully transi- tion from the SNF to home with home health care and fol- low- up with her primary care provider and the orthopedic surgeon who did the hip repair.

This example shows the pos- sible outcomes of a complex patient moving through our cur- rent health-care system, which involves multiple medical providers, various physical locations, and a changing level of care required by the patient.

In order to ensure this patient receives the best quality of care, each team of nurses, thera- pists, physicians, and social workers must work together to successfully transition the patient from one level of care to the next which includes moving from health-care venues as varied as hospitals, acute rehabilitation centers, skilled and subacute nursing facilities, long-term care facilities, assisted living homes, home health care, and hospice facilities.

Hospital Discharge Process

Planning for a transition in care begins while a patient is in the hospital. As part of the Medicare Conditions of Participation, hospitals are required to employ and document a discharge planning process for all patients and must

M.M. Brown (*) UNC Dept. of Family Medicine, University of North Carolina, Chapel Hill, NC, USA e-mail: Mallory_mcclester@med.unc.edu

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identify those who are likely to suffer adverse health conse- quences after discharge in the absence of adequate discharge planning. Due to increasing pressure to shorten the length of a hospital stay, patients are less likely to stay hospitalized until they feel “better” as was the case in the past. Decreasing length of stays leave limited time for educating patients and families in the hospital [13].

In 2004, a quarter of Medicare patients were discharged from a hospital to a nursing home or rehabilitation facility. A more recent study of Medicare beneficiaries that looked at the 30-day period following hospital discharge showed that 60% of patients made a single transfer, 18% made two trans- fers, 9% made three transfers, and 4% made four or more transfers [3].

All of this transitioning from one place to the next increases the likelihood that vital information will be lost and care plans will be fragmented [3]. To address this, many health-care systems have instituted transition of care programs that recognize that discharges from the hospital are most successful when a team-based approach is taken, including the physician, nurse, pharmacist, case manager, patient, and caregiver.

In the State Action on Avoidable Rehospitalizations (STAAR) trial, a hospital discharge nurse, pharmacist, or social worker identified patients at high risk for readmission and ensured thorough discharge planning including educating the patient [10].

Nurses developed a sys- tematic way of providing information to the patient, with a folder that included information about the patient’s care team, follow-up appointments, and treatment plan with edu- cational materials specifically tailored for the patient. Patients were also encouraged to write down their questions, to be answered by the nurse the next day.

The discharge nurse also led discussions at multidisciplinary rounds includ- ing reaching consensus on the estimated day of discharge for the patient. A pharmacist also worked on the transitions team throughout the hospitalization, anticipating medication issues and changes, educating the patient on the recom- mended medication regimen prior to discharge, reconciling the medications on the day of discharge, and provided coun- seling and a discussion about barriers to adherence.

The tran- sitions pharmacist often called the patient after discharge to again review the medication list.

Hospital-based case managers also have an important role in the discharge process. Case managers can uncover psy- chosocial issues or other causes that likely contributed to an admission or readmission. These members of the team are often best equipped to determine the level of care the patient entered the hospital with and to advise on the appropriate services needed at discharge [12].

Physicians play an important role on the discharge plan- ning team. They keep the team informed regarding timing of discharge and predicted needs at the time of discharge. The hospital physician is often the one who contacts the patient’s primary care physician for input on medical history as well

as updating him or her on the patient’s progress. A complete discharge summary available in a timely manner is also an important role of the physician and includes several key pieces of information that can reduce the risk of readmission (Table 30.1).

Some practices will send a liaison from the practice to the hospital to help coordinate care by sharing information about the patient with the hospital team, alerting the practice of the admission along with the anticipated date of discharge, and ensuring that the practice anticipates post-discharge issues and provides timely follow-up [5].

The patient and the family also play an important role in the discharge process. They help in deciding the next loca- tion of the patient’s care, when follow-up will occur, and who to contact if a problem arises.

They must also under- stand the updated medication list, when and how to take the medications, and potential side effects. Ideally, they can describe a system for taking their medication prior to dis- charge. It is also important to ensure that the patient and fam- ily have some understanding of the reason for admission and the diagnosis [3].

In all transition models, communication is vitally impor- tant. Establishing the patient’s health literacy is key in pro- viding effective discharge instructions. The teach-back method (confirming whether a patient understands what is being explained to them by asking them to repeat it back) is an easy, inexpensive way to improve patient education at the time of discharge [14].

Care After Hospitalization

The highest-risk patients will benefit from close follow-up which can include a phone call, a home health visit, or an office visit within 48 h, all of which can reduce the risk of rehospitalization. A report in 2004 suggested that only 50% of the 2.3 million Medicare enrollees readmitted within 30 days were seen by primary care providers in the interim between the hospitalizations [11].

Post-hospitalization phone calls are a cost-effective read- mission prevention strategy [5, 16]. These phone calls should include asking the patient if they have filled their prescriptions;

Table 30.1 Key components of the discharge summary for a patient with high likelihood of readmission

Overall goals of care Chief complaint, reasons for admission

Functional status (ADLs, IADLs)

Medication list, including changes

Therapy needs Durable medical equipment

Typical residence Advance directives

Primary caregiver, support at home

Medical hospital course

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ensuring the patient knows how and when to take the medica- tions; discussing the patient’s understanding of critical ele- ments of self-care; reviewing why, when, and how to recognize worsening symptoms and when and whom to call for help; and confirming the date and time of the follow-up physician appointment as well as ensuring transportation is arranged [5]. Follow-up with the primary care provider decreases readmissions especially if scheduled within 1–2 weeks of discharge. Timely appointments require good communication between the inpatient team and the outpatient provider’s office. In addition to the timeliness of follow- up, other key components of a successful hospital follow-up office visit include preparing the patient and the office clinical team before the visit, assessing the patient and initiating a new care plan or revising the existing care plan during the visit, and communicating and coordinating the ongoing care plan at the conclusion of the visit with the patient and the care team [5]. The visit should also include a review of the patient’s health-related goals to ensure there is agreement between the care team and the patient. The patient should be asked about factors that contributed to the hospitalization or emergency department visit and correct modifiable factors that might reduce the likelihood of a future admission. The medications should be reviewed again to reduce medication errors and increase compliance with an updated medication list printed for them. Follow-up labs, tests, and discussion of the need for additional workup should also be addressed. Patient under- standing of the plan is assessed and reviewed in language they can understand along with the opportunity to ask questions. The visit should end with agreed-upon goals of self-manage- ment, a scheduled follow-up visit, and instructions on reasons to return earlier. Checklists can help with post-hospital fol- low-up visits [5]. Note templates can also be created in the electronic medical record.

Reasons for Readmission

The success or failure of transitions of care in preventing rehospitalizations depends on the nature of the intervention, the setting of implementation, and the population of patients [4]. Many tools exist to predict hospital readmission, but inconsistencies in the data prevent us from knowing which risk factors are most predictive [5]. Older age, prior hospital- ization, poor family or social support, low health literacy, high medication burden, and numerous specific medical conditions increase the likelihood of readmission [1, 3] (Table 30.2).

In addition to these risk factors, readmissions have other causes including poor communication, medication issues including misunderstandings of instructions during hospital- ization or at discharge, inadequate patient comprehension of diagnoses and follow-up needs, and failure to complete

planned outpatient diagnostic or treatment plans [9]. The risk of readmission is highest shortly after discharge which is when medication errors are likely to occur and intended or pending tests are not followed up (outpatient test recom- mended but did not take place). This is likely due to poor communication between hospital physicians and the pro- vider seeing the patient after discharge or between the dis- charge team and the patient. Patients often do not understand risks and benefits of medication changes, when they can resume normal activity, what questions they should ask, and warning signs for which they should watch. Many patients are discharged from the hospital with intravenous access lines, complex wound care, enteral feeding devices, cathe- ters, surgical drains, and other types of devices that are com- plicated and can lead to readmission if the patient is not managed appropriately [13].

Timing of Interventions

Interventions to reduce readmissions can be classified by timing (pre-discharge, post-discharge, interventions that bridge the transition) and use several methods such as discharge plan- ning protocols, comprehensive assessments, discharge support arrangements, and educational interventions [2].

Pre-discharge

Planning ahead while the patient is still in the hospital is con- sidered pre-discharge planning and includes patient educa- tion, discharge planning, medication reconciliation, and scheduling the follow-up appointment before discharge [3]. Collaborating with the outpatient provider during hospital- ization and asking the patient and caregiver’s preference for appointment scheduling after discharge can help ensure opti- mal outpatient follow-up care [6].

Prior to discharge, the discharge summary is completed and provides a clear, organized, and complete story of the hospitalization [6]. It is a key mode of communication that bridges care from the hospital to the next setting. Medication reconciliation is an important part of this process, as medica- tion errors or effects are a leading cause of readmission [8].

Table 30.2 Risk factors for hospital readmission

Heart disease Medicare/Medicaid eligible Prior hospital stay

History of stroke

Requires caregiver for assistance with ADLs

Cognitive impairment

Diabetes Inadequate social support Extensive medication list

Cancer Inadequate preparation from caregivers

Poor compliance

Depression Poor health literacy

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Patient education at discharge helps the patient and caregiver understand the relevant disease process, the events during the hospitalization, medication changes, expected follow-up, and who to contact if concerns arise regarding a change in their health status. For higher-risk patients, a patient “coach” has been shown to be useful in improving self-management skills [6, 18].

Post-discharge

Post-discharge interventions include telephone calls, hotlines, home visits, and timely outpatient follow-up. Follow-up tele- phone calls have been studied with and without a script. A script may include plans for follow-up, discussion of new symptoms, and review of medication availability [3]. Outpatient follow-up may be best with the patient’s primary care provider according to studies that have shown increased risk of admission when seeing an unfamiliar provider [9]. Interventions to reduce hospitalization that include the outpa- tient are more successful than inpatient-only interventions [4].

The State Action on Avoidable Rehospitalizations (STAAR) trial reported that post-discharge phone calls from the pharmacist found that 52% of patients deviated from med- ication instructions after leaving the hospital which included patients continuing on medications that had been discontin- ued during the hospitalization, using over-the- counter medi- cations that were not mentioned during the hospitalization, and confusion regarding proper dosing instructions for medi- cations that were initiated or changed at discharge [10].

Bridging the Transition

Bridging interventions support the patient during a vulnerable time and educate, empower, and activate the resident in his or her own care. Useful strategies include patient- centered dis- charge instructions (PCDI), transition coaches, and provider continuity from inpatient to outpatient. The PCDI is an inpa- tient teaching tool that also provides discharge instructions.

For higher-risk patients, a “coach” has been shown to be useful in improving the patient’s self-management skills [6, 18]. A transition coach bridges between the inpatient setting where efforts focus on disease-specific education and assess- ment of social needs and the outpatient setting where the coach focuses on medication adherence, ambulatory follow- up, and symptom monitoring.

Evidence is scarce to support any one strategy over another for reducing the likelihood of readmissions [2]. Single interventions, when evaluated in isolation, have not consistently demonstrated statistically significant changes in readmission rates. Even when interventions are bundled, there is no consistent solution to decreasing readmissions.

Still, there is agreement that a multidisciplinary approach to improving care coordination must be a part of effective efforts to reduce avoidable readmissions [4, 21].

Programs in Transitions of Care

A number of studies have looked at effective practices in transitions of care. The Care Transitions Intervention (CTI) utilizes a nurse transition coach who educates and empowers patients to better navigate their own care. The CTI empha- sizes four “pillars”: medication self-management, a patient- owned health record, follow-up with a primary care provider or specialist, and awareness of “red flags.” The intervention lowered 30- and 90-day readmission rates and reduced read- missions [18, 20].

Project Re-Engineered Discharge (RED), developed by Jack and colleagues, addresses both the system and patients’ navigation of the discharge process through 11 mutually reinforcing components, many of which have been discussed previously (Table 30.3) [22]. When implemented in an urban university hospital, participants in the program had a low- ered rate of 30-day hospital utilization (emergency depart- ment visits and rehospitalizations) [7, 19, 20].

Project BOOST (Better Outcomes by Optimizing Safe Transitions) was designed to identify high-risk elderly patients early in the admission process [23]. This program provides resources to optimize the hospital discharge process and minimize issues older patients face after discharge from the hospital. Hospitals may use the BOOST toolkit, which

Table 30.3 Components of discharge planning that reduced hospital utilization within 30 days of discharge [7]

Educate the patient about his or her diagnosis throughout the hospital stay

Make appointments for clinician follow-up and post-discharge testing

Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up the results

Organize post-discharge services

Confirm the medication plan

Reconcile the discharge plan with national guidelines and critical pathways

Review the appropriate steps for what to do if a problem arises

Expedite transmission of the discharge summary to the physicians (and other services such as the visiting nurses) accepting responsibility for the patient’s care after discharge

Assess the degree of understanding by asking them to explain in their own words the details of the plan

Give the patient a written discharge plan at the time of discharge

Provide telephone reinforcement of the discharge plan and problem-solving 2–3 days after discharge

Adapted from: Jack et al. [7]

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promotes collaboration and allows programs to learn best practices from each other. It has reduced the 30-day readmis- sion rate and improved communication and collaboration during and after hospitalization.

Summary

Well-executed transitions of care incorporate patient’s indi- vidual goals, needs, and values [3]. An ideal transition includes effective communication of information, patient education, enlisting the help of social and community sup- ports, ensuring continuity of care, and coordinating care among team members, all done in a timely manner [6]. Anticipating problems that may arise after discharge, related to the disease exacerbation or to a psychosocial dynamic, and then undertaking actions in response to these problems have been effective.

Specifically listing issues that require attention at the first follow-up visit is also important in a suc- cessful transition. There is little evidence to support one spe- cific plan, and the best approach likely varies with the needs and practices of specific communities [4]. The themes that persist in any plan include the need for a comprehensive approach that promotes transition planning before, during, and after hospitalization. The most successful interventions are flexible and accommodate the individual patient’s needs [4]. To reduce readmissions to the hospital, health-care sys- tems must incorporate multiple interventions in an anticipa- tory manner rather than passively responding to the unwanted outcome of rehospitalization.

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