What They Are

"Readmission" occurs when patients who have had a recent stay in the hospital go back into a hospital again. Patients may have been readmitted back to the same hospital or to a different hospital or acute care facility. They may have been readmitted for the same condition as their recent hospital stay, or for a different reason. Often referred to as "rehospitalization."

Who's At Risk

Patients in transition - those moving from one care setting to another - are at increased risk for hospital readmission.  Unanswered questions including  the following, can increase patient risk for readmission: who is in charge of the patient transition, what is the plan, whether the plan and follow-up instructions are understood, and knowledge of whom to call with questions once they are home or in their new care setting.

What's At Stake

Patients move from one setting of care to another or to one set of care providers to another during an episode of illness. As patients and families navigate across new care settings and among different care providers, they often encounter communication challenges and confusion around who is clearly accountable for their care. This can lead to medical errors, duplication, increased costs and may also lead to higher rates of hospitalization.

What Providers Are Doing to Prevent Readmissions

Massachusetts is currently participating in many projects to address and improve hospital readmission issues.  These efforts are largely coordinated state-wide by the Massachusetts Care Transitions Forum, and a list of these projects follows.

• Potentially Preventable Readmissions (PPR) Project with 3-M
• STAAR Initiative:  STate Action on Avoidable Rehospitalizations
• Interventions to Reduce Acute Care Transfers (INTERACT-II) Initiative
• MOLST Demonstration Project:  Medical Orders for Life-Sustaining Treatment
• Project RED (Re-Engineered Discharge)
• Project BOOST (Better Outcomes for Older Adults through Safe Transitions)
• Home Care Projects:  Masspro Collaborative Project
• Business-led Projects:  Dovetail Health's Pharmacist-Led Transition Services to Avoid Costly Readmissions

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WORKING HARD TO REDUCE PREVENTABLE READMISSIONS:
A Gatefold Publication You Can Use 

One of MHA's Strategic Performance Improvement Priorities - reducing preventable readmissions - is garnering great attention in 2011. Hospital Boards of Trustees throughout Massachusetts are signing on to the three-part improvement initiative in which they pledge to address the issues of readmissions, mortality, and central line-associated bloodstream infections at their regular meetings; to advocate for healthcare policies that reduce incidences of the three issues; and to measure improvements in the three areas.

In February 2011, nearly 400 caregivers attended a two-day STAAR conference - or State Action on Avoidable Readmissions. STAAR is focused on improving care transitions to reduce readmissions. Twenty-two cross-continuum teams have been part of the STAAR project since September 2009, and 27 new teams came to the event to learn from their colleagues and begin their own work.

On the state and federal level, Medicaid and Medicare are, or are about to, institute penalties for excessive readmissions.

Now, Hospitals & Health Networks, the flagship publication of the American Hospital Association has produced this "Gatefold" publication on the readmissions issue. It lays out the numbers, key aspects of the Affordable Care Act relating to readmissions, the top seven hospital readmissions, and a checklist that STAAR states, such as Massachusetts, use to assess and remedy the problem.