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HEALTHCARE IS A TEAM SPORT: Hospitals, Doctors & Caregivers Working Together to Reduce Hospital Readmissions

Jane Noble
27 March 2013

Over 2 million Medicare patients, many of them elderly, are readmitted to the hospital for the same condition within 30 days of being discharged. These hospital readmissions are no doubt depressing for patients and their families, and the extra Medicare costs stack up to a daunting $17.5 billion annually.

A new report from the Robert Wood Johnson Foundation ( entitled The Revolving Door: A Report on US Hospital Readmissions analyzes hospital specific Medicare data provided by the Dartmouth Atlas Project and the Centers for Medicare & Medicaid Services and focuses on regional and hospital variation in readmission rates.  Patients’ chances of being readmitted are largely dependent on where they live and at which hospital they receive care. Data shows that from 2008 to 2010, little progress was made in reducing hospital readmissions among elderly patients, despite the efforts of many hospitals to improve transition and discharge procedures.

Public attention has been brought to this ongoing problem with the implementation of the Obama administration’s Patient Protection and Affordable Care Act. As part of the overhaul of the health system, hospitals will now be penalized for higher than expected readmission rates in an effort to force improvements in hospital quality. The act focuses particularly on readmissions for pneumonia, congestive heart failure and acute myocardial infarction. In October 2012, Medicare reimbursements to more than 2,000 hospitals were reduced where they had high readmission rates for these three main ailments. Three hundred and seven hospitals received the highest penalty – a 1% reduction in base Medicare payments. These maximum penalties increase to 2% in 2013 and 3% the following year.

Healthcare is extremely costly and until now, there has been no real financial incentive for hospitals to make sure that patients receive the right care once discharged. There has been an element of “out of sight, out of mind” thinking.  Hospitals, doctors and nurses are so busy with the next intake of patients that they have little time to think of patients who are no longer in their care or field of vision. These new regulations and hefty penalties will encourage hospitals to reevaluate their aftercare processes.

Of course not all readmissions are preventable. Some patients may be readmitted to finish their course of care. Others may return for a completely unrelated cause such as falling down and breaking a limb. Some patients may not have been well enough for further surgeries and need to get stronger before an operation can be scheduled. Many, however, are the result of a fragmented system that loses track of patients’ progress once they step outside the hospital walls.

The solution to the problem is complex, and the fault does not simply lie with the hospitals. Many different factors come into play and community wide commitment is needed if the situation is going to be improved.  It seems that full service care agencies, such as Amada Senior Care, have the opportunity to play an increasingly important role in assisting with the continuum of recovery care. Communication is one of the key issues. The patient is frequently alone during the discharge process. Patients may be well enough to leave the hospital, but are still not fully recovered – and they often have to absorb and retain all the information about their recuperation care. Family members are often not included at these meetings, even though they may be the main caregivers.

When one considers the long list of care quality problems that lead to readmissions, it becomes apparent that integrating care companies such as Amada into the discharge procedure might be one way to bridge the communication gap between the hospital and the exiting patient. Amada uses only professional, experienced case managers who are trained to take precise notes, ask the right questions and who know how to implement a care program. If Amada’s case management began at the discharge meeting, rather than later in the process, the patient would then have the support and guidance of the company overseeing their care at home. This could lead to much improved outcomes and the possibility of a more successful recovery. It would also leave the patient feeling more confident.

According to the Robert Wood Johnson report, there are many things beyond discharge planning and care coordination that lead to high readmission rates. When hospitals are the main source of care for a community and they have generally high admission rates, then it is likely that they will also have more readmissions, regardless of illness levels. Geographical differences also have an influence. The report cites at least nine interventions that have been shown to have positive benefits on readmission rates and discharge management – with follow-up being one of them. This is the area in which the expertise of care companies could prove invaluable.

To put a personal face on readmission numbers, the report commissioned Perry Undem Research & Communication to undertake in-depth interviews with 16 patients who have experienced a recent readmission: four family caregivers and 12 health care providers who care for patients who have been readmitted. They share their opinions and attempt to shed light on why so many patients end up back in hospital. The interviews were held in December 2012 and January 2013 in metropolitan Washington, D.C., New York City, and Dallas. Each case is individual and complex, but there are common traits in the stories shared. Based on the interviews and analysis of other readmission data, here are ten of of the most basic repeat reasons why patient recovery was hampered in some way through a less than perfect discharge process.

  1. Some patients left the hospital with a treatment plan for one illness while other problems of equal importance were ignored.
  2. Some patients were discharged without understanding their illnesses or treat­ment plans.
  3. Some patients discontinued taking medicine because they didn’t realize its importance.
  4. Some patients left without the right prescriptions for new medication.
  5. Some patients were not able to get to the pharmacy to fill their prescriptions.
  6. Busy schedules resulted in some physicians not communicating with each other but treating the patient in a vacuum.
  7. Many post-discharge care plans were disjointed or non-existent.
  8. Appointments with primary care clinicians or with specialists did not occur soon enough after discharge so that warning signs of deterioration could be detected.
  9. Some patients were simply unable to get themselves to the doctor.
  10. Some patients were unsure about diet and exercise regimens.

A full service care company like Amada can offer assistance in almost every one of these areas. When one considers the huge toll of readmissions in the healthcare system, it would seem a beneficial move for care companies to partner with hospitals and possibly assume some of the responsibility for the discharge process. They could become the missing communication link and immediately provide a point of contact for patients and their families once the hospital stay is over. At present, accountability is scattered among hospital staff, community physicians and nurses, skilled nursing facilities, and families.  Patients are unsure which clinician is responsible for their health once they go home. Many of the problems that can result in dire consequences for patients are actually straightforward non-medical challenges, yet these can pose almost insurmountable obstacles for some patients.

Healthcare needs to be a team sport. The best teams are not just made up of talented, individual athletes, but know how to function as one unit, communicating, complementing and supporting each other, to create something more than the individuals could alone. As Aristotle said: “ The whole is greater than the sum of its parts.”

Given that they both played college football together, Tafa Jefferson and Chad Fotheringham, Amada’s CEO and President, know quite a bit about working together. They have applied many of the principles of successful teamwork to their business and are ready to embrace the possibility of working more closely with hospitals.

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