Healthcare News & Insights

Research identifies 6 strategies to prevent readmission of elderly patients

You’re probably well aware of the statistic: Nearly one in five Medicare patients is readmitted to the hospital within 30 days. New research offers insight into methods hospitals can use to try to cut readmissions rates of the elderly.

NurseAndPatientThe research, conducted by Yale University, specifically focuses on one of the most common conditions leading to hospitalization in older people: heart failure. A costly condition to treat, it’s also an illness that often leads to readmissions, and the feds are putting pressure on hospitals to reduce overnight stays related to heart disease.

After examining data from nearly 600 hospitals, researchers compared readmission rates and determined that the most successful hospitals all used similar tactics to reduce the likelihood that an elderly patient admitted for heart failure would land in the hospital again.

An article in the New Haven Register summarizes the six strategies these hospitals used to cut readmissions in older patients. They are:

  • partnering with community physicians
  • partnering with other local hospitals
  • assigning responsibility for medication reconciliation to nurses
  • sending patients home with a follow-up appointment already scheduled
  • directly sending patient discharge summaries or electronic medical records to the patient’s primary care physician, and
  • assigning staff members to follow up on test results after the patient’s discharge.

These steps seem simple enough. But researchers found that a mere 30% of hospitals involved in the survey were using any of these strategies to prevent readmissions.

Out of those hospitals, the ones with the lowest readmissions rates used more than one of these tactics, proving that the best results come from combining multiple strategies.

Successful programs

In fact, many hospitals are trying programs that incorporate several of these strategies to reduce readmissions for other high-risk Medicare patients, and they’ve experienced great success.

One such program, the Care Transitions Intervention (CTI),  is used in hundreds of hospitals across the country. According to a recent article by Reuters, the program, developed by Dr. Eric Coleman from the University of Colorado Health Sciences Center, starts once the patient is admitted to the hospital and continues for four weeks after discharge.

Elderly patients are visited by a “healthcare coach” during their hospital stay. After discharge, staffers visit the patient at home, and make three follow-up phone calls to make sure the patient is taking all required medications and is properly following all discharge instructions.

CTI is designed to empower elderly patients and their caregivers to take full control of the patient’s health after leaving the hospital, and it has produced promising results. For example, one health system in Texas has 4% readmission rates for patients participating in the program. By comparison, its normal readmission rates for Medicare patients stood at around 18%.

Whether you consider participating in a similar initiative, or begin forging community healthcare partnerships and tweaking your discharge process, using any of these strategies can be helpful in the fight to lower readmissions.


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