Participation in the ACC’s Hospital to Home (H2H) Quality Improvement Initiative has helped to improve hospital readmission strategies including tracking discharged patients, partnering with local hospitals, and more, according to a study published Jan. 6 in JAMA Internal Medicine.

Additional Resources ACC’s H2H Initiative ACC Launches New Quality Improvement for Institutions Program Fine-Tuning Readmission Reduction Strategies to Improve Patient Care

The authors looked at survey data from 594 U.S. hospitals enrolled in the H2H program, and compared implementation of readmission strategies from 2010 to 2012. Results showed that in the follow-up survey, “significantly more hospitals were partnering with other local hospitals to reduce readmissions (30.7 percent vs. 22.9 percent; P=.002), were discharging patients with a follow-up appointment already made (61.1 percent vs. 52.4 percent; P=.005), and were tracking the percentage of patients who were discharged with follow-up appointments within seven days (43.0 percent vs. 32.2 percent; P<.001) and those readmitted to other hospitals (19.0 percent vs. 12.0 percent; P=.001).”

Additional strategies that showed improvement include use of electronic health records to more formally track readmissions, as well as “teach-back” techniques for the patient to better understand the provider’s instructions. Further, more hospitals were providing action plans to patients discharged with heart failure, and performing follow-up calls for additional education.

However, the authors did find areas for improvement, including a process for alerting outpatient physicians about discharges within 48 hours, follow-up of test results returned after the patients were discharged, sending the discharge summary to the primary care physician, and nurse-to-nurse reporting before discharge to a nursing home.

“Our work provides national data among a group of hospitals most likely to engage in improvement activities and may partially explain the slow rate of improvement in readmission rates nationally,” the authors note. Moving forward, “more consistently implemented strategies to promote safe transitions from hospital to home are likely critical for reducing readmission rates in the years ahead,” they add.

“Hospitals and health care professionals are responding to the challenge to improve the care of discharged patients and implementing strategies to improve care,” said Harlan M. Krumholz, MD, SM, FACC, co-author of the study. “Nevertheless, we are still in the midst of the journey and our study identified some potentially helpful strategies that are not yet being embraced.”

Keywords: Quality Improvement, Nursing Homes, Patient Readmission, Physicians, Primary Care, Patient Discharge

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