Unnecessary hospital readmissions are not just a substantial cost burden, but they can carry with them markers of inadequate quality and represent a rupture of care at some point along the patient’s intake-stay-discharge experience.

Reducing avoidable readmissions has become a viable object of study itself, evidenced by the pioneering work of projects like Eric Coleman’s Care Transitions Program at the University of Colorado and Mary Naylor’s Center for Transitions and Health at the University of Pennsylvania. The innovators of both programs, along with another two dozen related experts, brought their ideas together at the behest of the Health Research & Educational Trust, which published in January a compendium of their analyses in an instructional guide called Health Care Leaders Action Guide to Reduce Avoidable Readmissions.

The action guide collects the working—and effective—aspects of the various models, measures them out, and boils them down to create a “starting point” from which not only hospital leaders but health care practitioners in many roles can establish and implement practical changes within their own organizations and practices.

“We tried to tease out of those programs some of the elements that contribute to improving this area,” says Maulik Joshi, DrPH, president of HRET. “Readmissions is like human physiology. There are a lot of systems and there are a lot of connections between these systems. It’s a complex problem.”

To make things easier, the instructional paper creates a simplified action list based on a four-step approach:
            1.            Examine your hospital’s current rate of readmissions.
            2.            Assess and prioritize your improvement opportunities.
            3.            Develop an action plan of strategies to implement.
            4.            Monitor your hospital’s progress.
                        (Source: Health Care Leaders guide)

The guide delves into the four steps in greater detail, and it also provides action areas that, for optimal results, health care practitioners must seek to address at three distinct stages: during hospitalization, at discharge and post-discharge. What’s striking in this loose action plan is the opportunity for case managers to perform.

“Overall, case managers play a vital role in this because they are at the point of care at a time when a lot of these steps are going to be taken,” says Joshi. “Since these are complex and complicated issues, you need people who are at the point of care who can provide that case management-type perspective.”

Take, for instance, the opportunities present during hospitalization. The guide recommends that a member of the care team “risk screen patients,” “establish communication with primary care physician, family, and home care,” and “coordinate patient care across multidisciplinary care team.” During discharge, action steps call to educate the patient, schedule follow-up appointments, assist with medications, and “facilitate discharge to nursing homes with detailed discharge instructions and partnerships.” Finally, post-discharge necessitates “patient self management,” “follow up with patients via telephone,” and an establishment of community networks. For many of these steps, it is case management at its best.

The Health Care Leaders guide also includes detailed strategies, matching the action items with the institutions around the country currently utilizing them and predicating it all on the amount of work or resources it takes to implement each item. Some effective strategies like risk screening are relatively easy to implement, while others, like a full coordination of care across the multidisciplinary care team, will take greater effort.

One of the keys, according to Joffi, is the big-picture view, in which case managers specialize because of their intrinsic purview and responsibility. “They look at the whole case of the person,” he says.