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April 29, 2013

Hospitals’ Focus On Readmissions Is Wrong Approach


Many hospitals are focusing on reducing patient readmissions within 30 days of discharge because of a concern that readmission represents a failure of medical care.

But they're wrong.

Focusing on readmissions alone can be counterproductive because the motivation is not necessarily related to delivering better care. A Journal of General Internal Medicine study of Medicare recipients and readmission rates said: “Hospitals with greater adherence to recommended care processes did not achieve meaningfully better 30-day hospital readmission rates.” Instead, the focus is due to new Medicare penalties for hospitals that have “too many” readmissions within 30 days. According to a Kaiser Health News analysis, 54 Massachusetts medical centers will lose money because of high readmission rates.

However, the real problem is that hospitals are designed to treat acute care needs: Treat patients quickly and release them. But the cause of increasing readmissions is mostly the existence of multiple chronic conditions among an aging population.

Despite the best treatment, many of the chronically ill will be readmitted often. They might need an extra day or two in the hospital to get stronger. Since the cost of keeping a hospital bed empty is nearly equal to that of keeping one in use, it would, in many cases, make medical and economic sense to keep such patients a little longer, and it might reduce readmissions.

That's why it's imperative that we transform our health care mindset from acute care to chronic issues. Instead of penalizing hospitals for high readmission rates, Medicare and state programs should consider allowing patients to spend an extra day recuperating.

For example, a patient may be admitted for pneumonia, and once it has been treated, the patient will be discharged. Yet the patient will still have congestive heart failure and chronic obstructive pulmonary disease, which make it difficult to breathe, predisposing him or her to contracting pneumonia again.

Some hospitals have taken the wrong path. Rather than be penalized for the almost-certain readmission rates of seniors with chronic conditions, they've developed programs to avoid re-admissions. The practice of "observing" patients in hospitals rather than admitting them is rapidly increasing. "Observed" patients don't fall under readmission scrutiny; they're sent home within prescribed time limits without having received much care. Since Medicare will only cover time in a rehabilitation or other transitional care facility after hospitalization, patients may not be eligible for coverage of a stay in a transitional care facility if they're being "observed." If that's the case, and it's explained before a transfer to transitional care, the patient may opt to simply return home, where support may be inadequate, and it would increase the chance of complications and readmission.

In fact, a more significant determinant of whether patients will need to be readmitted, or require admission at all, is the care and support seniors receive outside the hospital. The World Economic Forum's monograph, “Global Population Aging: Peril or Promise,” states: “Health systems for older adults that optimize health in aging must include more than care to respond to the presence of illness. Prevention matters, both for the individual and for communities.” Follow-up visits, more education at discharge, or transitional support at home can help reduce the likelihood of readmissions.


Bruce L. Bender is a fellow of the American College of Physician Executives and owns Home Instead Senior Care of Northborough and Natick.

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