Preventing Avoidable, 30-Day Hospital Readmissions

A readmission is an unplanned inpatient admission to the hospital within 30 days of the initial hospital discharge date and is measured and tracked by the Centers for Medicare & Medicaid Services.¹ Many readmissions are preventable and can often be attributed to avoidable factors, such as issues in post-discharge communication, planning, and follow-up. Identifying the gaps in care that cause readmissions is an important step in improving care transition practices and deciding which areas need focused process-improvement projects.²

High-utilizers—patients with four inpatient admissions or six emergency department visits within one year—make up a larger proportion of readmission visits and often require more social services interventions than a typical diagnosis-driven readmission.³

Know your readmitted patients by tracking and trending high-utilizer status; readmission sources; and unmet needs of readmitted patients, such as social determinants of health, undelivered durable medical equipment, and delay or non-arrival of services like home health.³ Ensure effective patient and caregiver education by using teach-back, a communication confirmation technique used to validate whether a patient (or caretaker) understands what is being explained to them.

Visit https://www.hsag.com/hqic/tools-resources/readmissions/ for readmission and care transition tools and resources. Reach out to your Quality Advisor for assistance with readmission prevention.

Hospital Readmission Rates

Data show there has been improvement in the all-cause readmission rate since the baseline period of 2019 (lower rates are better).

Visit the HSAG HQIC Quality Improvement and Innovation Portal (QIIP) to view your readmission data by selecting the Measure category of Readmit-Mortality and the Measure of Readmissions: All-Cause.

Source: Medicare Fee-for-Service claims data. For additional details on measure specifications, please reference the HSAG HQIC Compendium of Measures. The baseline time period is 01/01/2019–12/31/2019. The current time period is 08/01/2022–07/31/2023.

SEP-1 Is Now a Part of Value Based Purchasing (VBP)

The SEP-1 core measure—the severe sepsis and septic shock management bundle—is now a part of VBP. The baseline period is calendar year 2022, and the performance period is calendar year 2024. The payment adjustment period is federal fiscal year 2026 (October 2025–September 2026). Find details at QualityNet.

Please reach out to your Quality Advisor if you would like assistance with meeting this measure or email HospitalQuality@hsag.com. 

Ensuring Medication for Opioid Use Disorder (MOUD) Treatment Through the Care Continuum

This webinar series—a collaboration of all Quality Improvement Organizations—provides strategies, interventions, and targeted solutions to ensure Medicare beneficiaries have access to MOUD treatment and to facilitate continuity of care through the healthcare continuum.

Next: January 12, 2024 | 12 noon ET (9 a.m. PT).

Care Coordination

Quickinar Series

Discover ways to manage avoidable hospital readmissions by registering for these short, 30-minute webinars (quickinars)—offered monthly January through May 2024. Find details and recordings for past presentations on the webpage.

1st Tuesdays. Next: February 6, 2024 | 2–2:30 p.m. ET (11 a.m. PT)

Find on-demand quickinar recordings, slides, and podcasts for past HSAG HQIC learning series.

Health Equity Quickinar Series

Patient/Family Engagement Quickinar Series

Quality and Safety Quickinar Series

References

1 McIlvennan CK, Eapen ZJ, Allen LA. Hospital Readmission Reduction Program. Circulation (2015). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439931/

2 Harrison PL, Hara PA, Pope JE, Young MC, Rula EY. The impact of postdischarge telephonic follow-up on hospital readmissions. Population Health Management (2011). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128446/

3 Schickedanz A, Sharp A. Hu YR, et al. Impact of Social Needs Navigation on Utilization Among High Utilizers in a Large Integrated Health System: a Quasi-experimental Study. J Gen Internal Med 34, 2382–2389 (2019). https://doi.org/10.1007/s11606-019-05123-2

This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No XS-HQIC-XT-01092024-01