Most statistics suggest that approximately 1 in 5 Medicare patients (20%) are readmitted within 30 days. As shocking as this number may sound, it may even be an underestimate, because it doesn't include many patients under the age of 65 who are also stuck in the revolving door of frequent readmissions.
One of the key areas of focus has got to be better community care and follow-up, but how do we go about identifying these high-risk patients in the first place? Frontline hospital physicians, including myself, are all too familiar with the fact that a huge proportion of patients we admit to the hospital have been discharged in the not too distant past, sometimes as soon as the day before. It's the first thing we see when we scroll through the records of our new admission—what we call a “bounce back”. Equally, most physicians (and for that matter nurses and case managers) will instinctively know as soon as they discharge a patient, who is likely to be back very soon.
Over the last several years, there have been lots of clinical tools developed by academics to try to predict which patients are at the highest risk for readmission. Some in the “health care innovation” world have also tried to get computers and information technology in on the act. But at the end of the day, one can develop clinical tools till the cows come home, but rarely does it outstrip the good common sense of the people working at the frontlines.
Patients at a higher risk of readmission can easily be predicted by their recent history, clinical state, and social situation. The world of healthcare should identify these patients early on and immediately plough resources into working out what can be done upon discharge to keep these patients healthy in the community. There also needs to be better communication between the hospital and primary care teams, the patient's family, and also all of the specialists that may be involved in follow-up. And although we are focused on 30 day readmissions, because that's what the system uses as a measure, frequent admissions even within 60 or 90-day periods are also just as much of a problem and shouldn't be ignored. By zeroing in on these high-risk patients and keeping them healthy and out of the hospital, we are being the best doctors possible.
