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INTRODUCTION — Discharging patients from the hospital is a complex process that is fraught with challenges. Preventing avoidable rehospitalizations has the potential to profoundly improve both the quality-of-life for patients and the financial well-being of healthcare systems.
There were over 39 million hospital discharges in the United States in 2006 . Among Medicare patients, almost 20 percent who are discharged from a hospital are readmitted within 30 days . Unplanned rehospitalizations, at a cost of $17.4 billion, accounted for 17 percent of total hospital payments from Medicare in 2004 [2,3].
While the exact number of avoidable readmissions is unknown, a systematic review of 34 studies, most based on retrospective chart review, found that between 5 and 79 percent of readmissions were likely to be preventable . Decreasing the rate of hospital readmissions has been targeted as a high priority for US healthcare reform . In 2012, the United States government started to penalize hospitals for excess readmissions, initially involving up to 1 percent of total payments from Medicare . Approximately two-thirds of US hospitals realized some penalty under this program in 2012. These penalties will rapidly rise to up to a maximum of 3 percent of total Medicare reimbursement by 2015. Readmission rates are calculated on a rolling three-year basis; each year, the penalty will be determined based on the previous three years for which data is available (eg, for fiscal year 2013, the data comes from 2009, 2010, and 2011). These penalties, anticipated to yield CMS over $300 million in savings (averaging over $130,000 per penalized hospital), result in even greater scrutiny of the discharge process and methods to prevent readmissions.
This topic presents an overview of the discharge process, determination of the appropriate next site of care, and review of interventions that have been developed to reduce the likelihood of unplanned readmissions and adverse events after discharge. Much of the discussion relates to structures for care within the United States; availability of services and types of facilities vary significantly across geographic areas.
APPROPRIATENESS FOR DISCHARGE
Need for ongoing hospitalization — The medical necessity of continued hospitalization is primarily determined by the presence of an acute health condition of sufficient severity that ongoing diagnostic or therapeutic intervention, or careful monitoring, is required.
However, patients often appropriately remain in the hospital when these criteria are not met, due to the lack of a suitable alternative setting to provide necessary care or other social factors.
Premature discharge or discharge to an environment that is not capable of meeting the patient's medical needs may result in hospital readmission. In addition, early hospital discharge may not lead to overall cost-savings if it results in need for more intense subsequent healthcare utilization, including emergency department or nursing facility visits, as indicated by one observational study comparing patients who received hospital care from a primary care physician with care by a hospitalist .
DETERMINING THE POST-DISCHARGE SITE OF CARE — When it has been determined that a patient is medically ready for discharge, the health care team must determine the most appropriate setting for ongoing care. Determinants of the appropriate site of care involve medical, functional, and social aspects of the patient's illness. The patient’s acute and chronic medical conditions, potential for rehabilitation, and decision-making capacity must be taken into account .
Input is needed from multiple sources to determine the most suitable discharge plan. Involved parties often will include the patient, family, case manager, nurse, physician, physical and occupational therapist, social worker, and insurer.
In order for the patient to be deemed safe and ready for discharge to home or to a non-acute environment (rehabilitative, transitional, or chronic care), a provider must take into account a number of factors beyond the medical determinants. These factors include:
Discharge home — Approximately three-quarters of hospitalized patients are able to return to their home environment following discharge . For discharge home, patients, with help from family or other caregivers if available, should be able to:
Specific insurance benefits and availability of services in the community may also influence whether or not the patient may be safely discharged home. Home services, such as visiting nurses or infusion providers to administer intravenous infusions, may allow selected patients, who would otherwise need nonacute residential care, to manage their care needs at home.
Discharge to another care facility — If discharge to the outpatient setting is not appropriate, the team must then arrange transfer to another inpatient facility for ongoing care. Determining the most appropriate inpatient setting of care for ongoing treatment involves determining the patient's needs and matching needs with the capabilities of potential sites of care.
One model to help accomplish this involves assessing a set of parameters that describe generic clinical characteristics (medical and surgical issues, mental and emotional status, physical functioning, and environment) that are largely independent of the patient's specific diagnosis . Components of this model are shown in a table (table 1). These needs are then matched with the services offered at different types of facilities. (See 'Types of care facilities' below.)
Once it is decided that discharge to an alternate facility is necessary, referrals are made to facilities that are felt to be potentially appropriate, and the patient is screened for acceptance. The patient must consent to transfer to an accepting facility; if the patient or family declines, then negotiation ensues to find an acceptable discharge placement.
Types of care facilities — The severity of functional impairments and the need for assistance with activities of daily living (ADLs) often determines whether a patient can be safely managed at home, or requires care at a skilled nursing facility (SNF) or extended care facility (ECF). In making this determination, particular attention is paid to need for supervision in ADLs and safety awareness.
Medicare in the United States identifies three categories of health facilities:
Functional capabilities of each of these facilities are shown in a table (table 2) and outlined briefly here:
ELEMENTS OF THE DISCHARGE PROCESS
Discharge planning — Discharge planning is the development of an individualized discharge plan for the patient prior to leaving the hospital, to ensure that patients are discharged at an appropriate time and with provision of adequate post-discharge services . Such planning is a mandatory part of hospital accreditation .
Discharge planning is a complex process that seeks to determine the appropriate level of services required by the patient and then match the patient to an appropriate site of care . This process ideally begins at the start of the hospitalization. The hospital case manager should be involved as soon as it is clear that the patient will require services at home, or will require transfer to an alternative level of care.
The impact of discharge planning on outcomes appears to be limited. A 2010 systematic review identified greater patient satisfaction and small decreases in length of stay and readmission rates with discharge planning, while mortality rates were unchanged . A study that examined discharge planning for patients with heart failure measured chart documentation of discharge instructions and patient reports of the discharge planning they had received . No correlation was found between readmission rates and the chart-based measure, and only a small correlation was noted for lower readmission rates with highest versus lowest quintile on the patient-reported measure (22.4 versus 24.7 percent).
Medication reconciliation — Medication reconciliation, or medication review, is the process of verifying patient medication lists at a point-of-care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed relative to pre-admission medication lists. Performing an accurate medication reconciliation is a critical element of a successful discharge transition. It also provides an opportunity for clinicians to ensure that patients understand what medications they are taking, how to take them, and why they are taking them. Most studies included in a 2012 systematic review showed that medication reconciliation was associated with a decrease in actual and potential adverse drug events . Whether or not medication review reduces postdischarge emergency department visits and readmissions is inconclusive; however, we typically conduct a medication reconciliation for each patient that is discharged from the hospital and review the medication list with the patient and/or caregiver.
The first step is having an accurate medication list at hospital discharge, which depends on the following:
Once an accurate discharge medication list is generated, the clinician needs to communicate this information effectively to the patient or and/or caregivers. An observational study of patients aged 64 or older who were discharged home after hospitalization showed that the majority of patients did not understand the new dosing of medications they were taking or the reasons for medication changes . At discharge, nurses had reviewed all medications with the patients, but there was no formal process. This puts patients at increased risk for medication adverse events. In a systematic review of 26 studies, the medication reconciliation process consistently reduced medication discrepancies, as well as actual and potential adverse drug events . The most effective interventions targeted high-risk patients and had intensive pharmacy staff involvement.
Evidence was less robust that medication reconciliation reduces postdischarge emergency department visits and readmissions. A 2013 meta-analysis of five randomized trials of 1186 hospitalized adults, followed for 30 days to one year, demonstrated that medication review did not reduce the risk of hospital readmissions, but did show a 36 percent relative reduction in emergency department visits . Medication reconciliation may have a more important impact on the reduction of readmissions due to adverse drug events [19,20].
Discharge summary — The primary mode of communication between the hospital care team and aftercare providers is often the discharge summary, raising the importance of successful transmission of this document in a timely fashion. Unfortunately, the discharge summary reaches the primary care provider by the time of the first follow-up visit in only 12 to 34 percent of such visits, and even then often lacks key information .
Important elements in the discharge summary, as mandated by the Centers for Medicare and Medicaid Services, are :
This minimal content should be augmented by information critical to the aftercare providers. Utilizing a template for discharge summaries is helpful to ensure inclusion of relevant information . A suggested list of items that should appear in a discharge summary is shown in a table (table 3). An essential component is identifying those laboratory or other tests for which final results remain pending at the time of discharge [24,25].
Several initiatives involving computer-based innovations to improve the discharge summary process  or notification of pending tests at discharge  have been explored but issues involving cost and end-user adoption need further consideration. An initiative involving audit and feedback of discharge summaries was successful in improving discharge summary completeness . The Office of the National Coordinator for Health Information Technology (ONC) is supporting a pilot project to develop standardized data sets for transitions of care between acute and post-acute care sites and to measure the impact of those exchanges on healthcare service utilization .
Patient instructions — At the time of discharge, the patient should be provided with a document that includes language and literacy-appropriate instructions and patient education materials to help in successful transition from the hospital.
These documents should be brief, focused on critical information to the patient, and primarily directed at what the patient needs to understand to manage his or her condition after discharge.
One model for patient materials, developed by the National Patient Safety Foundation, is called Ask Me 3 :
1. What is my main problem? (ie, why was I in the hospital?)
2. What do I need to do? (ie, how do I manage at home, and what should I do if I run into problems?)
3. Why is it important for me to do this?
Discharge information, both written and verbal, should be reviewed with the patient/family caregivers with an emphasis on assessing and ensuring comprehension. In one interview study of patient perception and understanding of discharge instructions, among discharged patients aged >65 years who felt that they had good understanding of their discharge instructions, 40 percent were unable to accurately describe the reason for their hospitalization and 54 percent did not accurately recall instructions about their follow-up appointment .
Teach back is a technique by which the provider asks the patient or caregiver to explain the recently taught concept in the patient's own words . This technique permits the provider to identify and correct any misunderstandings in real time, with the intent of preventing adverse events related to inadequate comprehension of discharge information. While the teach back method has been validated in teaching a patient a new skill (eg, administering insulin or changing a dressing), teach back has not been studied specifically as a mechanism for reducing readmissions.
Discharge checklist — Checklists provide an effective mechanism for ensuring that discharge communications (the discharge summary and direct communication with both aftercare providers and patients/families) reliably incorporate all key elements. In 2005, a multi-institutional group created a discharge checklist containing a number of elements that are either required or optional during the preparation of the patient for discharge. This checklist has been endorsed by the Society of Hospital Medicine (table 4) . Its effectiveness has not been studied.
FACTORS CONTRIBUTING TO REHOSPITALIZATION — Many hospitalizations are not avoidable. Readmissions may represent progression in the natural history of the patient's underlying disease, a separate problem that is unrelated to the initial admission, or the consequence of patient inability to follow through with a discharge plan (eg, the patient does not fill prescriptions). Additionally, one study using Medicare data for over 200,000 heart failure and pneumonia patients found that high initial admission rates for those conditions in patients with similar morbidity were correlated with high rates of readmission and that this factor contributed to more regional variation in readmission rates than other factors including case mix, discharge planning, hospital size, or number of primary care or specialist physicians .
With efforts to decrease length of stay for hospitalized patients over the past two decades, a reasonable concern has been raised that early discharge, if premature, could increase rates of rehospitalization. In an observational study from 129 Veterans Affairs acute care hospitals in the United States, reviewing over 4 million medical admissions from 1997 to 2010 for patients with one of five diagnoses (heart failure, COPD, acute myocardial infarction, community-acquired pneumonia, and GI bleed), a decrease in 30-day readmission rates for all diagnoses (from 16.5 to 13.8 percent) occurred in conjunction with a decrease in length of stay (from 5.44 to 3.98 days) over the 14 years . Thus, at least within this hospital system, and given the limitations of an observational study, earlier discharge did not lead to an increase in rehospitalization.
Some readmissions are likely preventable , although the proportion of rehospitalizations that are preventable is uncertain. A systematic review of 34 studies found that the median proportion of readmissions deemed avoidable was 27 percent, but that variable and subjective criteria to define “preventable” readmissions led to a wide range of reported rates between studies .
Several factors that increase the likelihood of rehospitalization may be modifiable, especially those that relate to clinician or system level issues. Such factors include:
Therapeutic error — Medical errors are a major contributor to preventable rehospitalization. Issues related to medication use are a common form of error. Adverse events, most commonly medication-related, have been estimated to occur in approximately 20 percent of patients following discharge [37,38]. Approximately two-thirds of such adverse events were determined to be either preventable or ameliorable.
Examples of these types of errors include:
However, preventing therapeutic error post-discharge is challenging. In a randomized trial involving two tertiary care hospitals, an intervention involving pharmacist medication reconciliation at hospital discharge, pharmacist counseling, low-literacy aids, and post-discharge follow-up phone calls did not prevent clinically-important medication errors, which occurred in one-half of patients in both control and intervention groups . Almost a quarter of these errors were serious, while 13 percent led to rehospitalization or emergency department visits.
Failed handoffs — Poor information transfer from hospital-based providers to primary care providers occurs commonly. This may contribute to multiple adverse consequences, including the need for readmission, temporary or permanent disability, or death [21,37,38]. Tests that are pending at discharge often fail to be communicated to providers responsible for their follow-up [24,25,40]. Representative studies include the following:
Direct communication from hospital provider to aftercare provider is uncommon, and there are no clear or widely accepted standards about this communication. A meta-analysis revealed that only 12 to 34 percent of discharge summaries had reached aftercare providers by the time of the first post-hospitalization appointment . Additionally, discharge documentation was often inaccurate and lacked important information such as noting additional workup indicated following discharge.
Absent or delayed follow-up — The optimal time interval between hospital discharge and the first follow-up visit to a primary care or subspecialty provider is unknown. Many factors will contribute to this decision including the severity of the disease process being followed, the perceived ability of the patient to provide adequate self-care, and psychosocial and logistical factors.
Several studies have evaluated the association between rates of readmission and scheduled outpatient follow-up post hospitalization. Most studies affirm that patients who are scheduled or seen for posthospital follow-up are less likely to be readmitted [38,43-45]. Findings include:
Higher-risk patients — Efforts to prevent readmissions can be targeted to patients known to be at a higher risk for readmission, including those at higher risk for adverse events post-discharge. Screening for increased risk may help healthcare providers and organizations target resources to patients most likely to be rehospitalized. However, there are several caveats to this approach:
No screening tool will be perfectly accurate. Studies have found that clinical providers are not able to accurately predict which patients will require readmission . Efforts to develop prediction models for patients at high risk for rehospitalization have yielded only fair discriminative ability [47,48]. Additionally, in a systematic review of 26 models developed to predict rehospitalization, only one model focused on the prediction of preventable readmissions , a concept that is itself fraught with issues regarding the definition of “preventability” .
Risk factors for readmission — Several studies have suggested clinical and demographic parameters that may increase the risk of readmission.
Clinical factors include the following:
Demographic and logistical factors include:
One tool for identifying patients at risk of readmission, the LACE index , has similar discriminating ability to other models, although may have some advantage in terms of simplicity. This model incorporates the patients length of stay (L), the acuity of the patients admission (A), the degree of comorbid illness (C) as measured by the Charlson Comorbidity Index, and the number of times the patients has been to the Emergency Department in the last six months (E).
Another tool for identifying patients at higher risk for readmission is the 8Ps Risk Assessment Tool, proposed by the Society of Hospital Medicine . The 8Ps Risk Assessment Tool identifies risk factors for adverse events post hospital discharge. The risk factors are similar to those clinical, demographic, and logistical factors described above.
Discharge against medical advice — Patients who are discharged against medical advice (AMA) are also higher-risk patients. A large retrospective cohort analysis performed at an urban academic medical center demonstrated that patients who were discharged against medical advice had a higher rate of readmission (OR 1.8, 95% CI 1.69-2.01) and also a twofold increased risk of death, compared to those discharged by their physician . Discharge against medical advice was more likely to occur for admissions related to substance abuse, sickle cell disease, or HIV infection.
Patients who leave against medical advice should be informed regarding the disease-specific risks associated with premature discharge and the increased risk of death and readmission. Given the difficulty in engaging these patients with the medical community, efforts should be made to arrange appropriate post-hospitalization follow-up, in the hope of facilitating their access to medical care after hospitalization.
DISCHARGE AND POST-DISCHARGE INTERVENTIONS — Efforts to re-engineer the discharge process to assure a safe transition involve such issues as improved clinician communication, patient education, IT systems, involvement of community-based providers, and arrangements for prompt follow-up . Such interventions have the potential to substantially improve patient care and reduce healthcare expenditures.
Researchers involved in the expanding field of Transitions of Care (TOC) are evaluating the effectiveness of various approaches to improving the discharge process. One classification scheme to categorize these interventions is to consider them as: predischarge interventions (patient education, discharge planning, medication reconciliation, scheduling a follow-up appointment); postdischarge interventions (follow-up phone call, communication with ambulatory provider, home visits); and bridging interventions (transition coaches, patient-centered discharge instructions), physician continuity between inpatient and outpatient settings . Several predischarge interventions (discharge planning, medication reconciliation, templated discharge summaries, and discharge checklists) are discussed above. (See 'Elements of the discharge process' above.)
A 2011 systematic review of interventions to reduce rehospitalization identified 43 relevant studies, 16 of which were randomized trials and the remainder observational studies . Most involved small numbers of patients (only two included more than 400 patients), and many studies had quality limitations, including incomplete data and the possibility of unrecorded rehospitalization at another institution, estimated to miss 20 percent of such events. Only 5 of the 16 randomized trials demonstrated significant improvement in rehospitalization rates, and four of the five successful studies involved several simultaneous interventions, including patient-centered discharge instructions and a postdischarge telephone call. A 2012 systematic review of interventions at the time of discharge found that many types of interventions (including medication reconciliation, structured electronic discharge summaries, discharge planning, and facilitated communication between hospital and community providers) impacted favorably on outcomes including rehospitalization rates, patient satisfaction, and continuity of care . Due to heterogeneity in interventions, patient populations, and outcomes, it was not possible to identify which specific interventions had direct impact on measured outcomes. Notably, 26 of the 36 interventions investigated involved transitional care managers. Consistent with previous studies, the successful interventions noted in this review overwhelmingly involved multifaceted interventions, suggesting that reducing adverse events after discharge requires a multipronged approach.
Many multidisciplinary initiatives, known as disease management programs, have targeted patients with specific chronic diseases, to provide patient support, counseling, monitoring, and medication oversight through the continuum of care, including ambulatory, hospital, and hospital discharge settings. Disease management programs involving patients with heart failure are reviewed separately. (See "Strategies to reduce hospitalizations in patients with heart failure".)
Telephone call — Studies have looked at the impact of a telephone call from a member of the health care team following discharge on varying parameters of patient management. These calls have been initiated by various members of the care team, including:
Such calls have been moderately effective at reducing emergency department visits  and improving follow-up with ambulatory providers , but demonstrated a trend towards reduced hospital readmissions in only one study . A 2006 systematic review was unable to define a clear benefit from this type of intervention due to significant heterogeneity in the quality and design of this literature . Interestingly, the optimal origin of the post-discharge telephone follow-up (hospital based or ambulatory based) is also unknown. A systematic review of the literature examining the effect of a telephone follow-up initiated by the primary care provider showed no change in readmission rates but the intervention did improve rates of post-discharge follow-up with the primary care practice .
Home visits — Home visits made by a number of different types of providers have been shown to reduce need for rehospitalization. One trial illustrated that a single home visit by a nurse and pharmacist to patients discharged with a diagnosis of heart failure, with a goal of optimizing medication management, showed a trend towards almost a 50 percent reduced risk of unplanned readmission . Other studies looking at this question did not have as dramatic an effect on reduction in rehospitalization [82,83].
Telemonitoring — Use of telemonitoring devices have also been studied as a means for reducing readmissions. As an example, using an integrated telephonic stethoscope in conjunction with follow-up nursing calls in patients with heart failure reduced emergency department visits in one small study, and demonstrated a trend toward reduced readmissions and overall costs . Devices for remotely monitoring various physiologic variables, including blood pressure, heart rate, weight, and oxygen saturation have been repeatedly studied, mostly among heart failure patients, and have demonstrated variable effectiveness in reducing need for readmission .
Multiple interventions — Given the complexity of transitions of care associated with hospital discharge, several groups have developed and evaluated programs incorporating multiple initiatives to address many elements in the discharge process. Examples of such programs include:
Post discharge, the rate of hospital utilization (emergency department visits or hospital readmissions) was 31 percent for the intervention group compared to 44 percent for the control group. Patients in the intervention group were also more likely to follow-up with their primary care provider.
CLINICIAN RESOURCES — Several program initiatives are underway to investigate and facilitate interventions to promote improved hospital discharge processes. These programs and their websites include:
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