David W. Bowers, MD
President and Chief Medical Officer at Innovative Healthcare Teams, LLC
I read an interesting article, which was published in the August 2015 issue of the Journal of Evaluation in Clinical Practice, describing the 5 most common causes of unplanned 30-day hospital readmissions.
According to the article, “the strongest predictor of readmissions was a high number of Emergency Department visits, defined as at least 4 ED visits within the 6 months immediately preceeding admission.”
The article states that additional frequent causes of readmission include post-discharge complications resulting from admissions for treatment of chronic Cardiac and Pulmonary conditions; Hospital Discharges on Friday; and a long length of stay.
Other studies have indicated that the most common underlying reason for avoidable readmissions is related to patient misunderstanding of the reconciliation of their hospital discharge medications and their pre-admission home medications.
As a primary care physician and Chief Medical Officer of Innovative Healthcare Teams, I’ve emphasized and coached our teams that the primary drivers of success in reducing avoidable readmissions include:
- Effective Team Based Care communication and collaboration between the providers at the Emergency Department, Hospital and Ambulatory settings for all high risk patients
- Timely patient follow-up with their ambulatory primary care provider (PCP)
- Appropriate follow-up includes a phone communication from the PCP office to the patient within 3 days and a face-to-face visit within 7 days. Post-discharge medication reconciliation is a primary component of the 3 day phone follow-up and the 7 day face-to-face visit
Our experience is that Team Based Care is the basic building block of success in Value Based Payment models regardless of the structure of the provider organization.