5 Ways to Reduce Readmissions and Give Patients the Best Chance to Recover Fully

The Hospital Readmissions Reduction Program (HRRP) which went into effect in 2012, allows Medicare to reduce its payment to hospitals that report higher than average patient readmission rates. It is considered a readmission when less than 30 days after discharge, the patient is readmitted due to complications from the original health issue. The rising cost of providing services, coupled with sometimes overburdened hospital staff, make it important to reduce readmission rates as much as possible. This can be done by establishing consistent best practice routines to help discharged hospital patients fully recover at home.


According to the Institute for Healthcare Improvement, a comprehensive, multi-leveled approach provides the most consistent, favorable outcome following a patient's discharge from a hospital. While there are many different things that can be focused on, the most important areas to target are:

  • Patient Education
  • Home Health Care
  • Discharge Planning
  • PCP Appointment
  • Medication Education

Patient Education Answers Questions Before They Are Asked

A patient unaware of his condition/illness or post-surgical expectations is ill-equipped to navigate recovering at home. In some cases, the patient might ignore important developments that could be successfully addressed through a PCP if caught in time. Preparing the patient, prior to discharge provides the opportunity for questions to get answered and concerns to be addressed.

The patient and caregivers should be educated about:

  • Anticipated length of recovery at home
  • Expected difficulties during the recovery process such as itching while the incision heals, weakness following surgery or an illness, range of motion issues, etc. (What is and is not normal to experience)
  • When to call the PCP – temperature, new injury, concerns with healing process, medication side effects and other concerns that arise
  • Medication protocol with regard to what medications will be prescribed and how they should be taken.
  • The importance of staying hydrated and nourished during recovery.

Home Health Care Reduces Readmissions

Home Health Care News reports that having a home health care provider extend the length of each visit can reduce the chance of patient readmission. One study discovered readmissions were reduced by 8% when the home health care professional stayed one additional minute each visit.

Home health care reduces readmissions by having a professional check on the recovering patient at the patient's place of residence. Trained to check vital signs, ask the right questions, and check for physical decline, the home healthcare professional is often able to spot an issue before it escalates to the point of putting the patient back in the hospital.

Follow Up Appointments are Key to Recovery Success

Every patient should have a follow-up appointment scheduled with his or her PCP within the first seven days of being discharged and the appointment should be scheduled prior to the patient's discharge. The importance of this appointment is two-fold.

  1. Through a follow-up with the PCP, the patient can have questions answered about symptoms being experienced during the recovery process.
  2. The PCP can keep contact with the hospital staff as needed to work together to help the patient continue in the healing at home process.

Discharge Planning Coordinates Everyone Involved

Best case practices to reduce readmission should always mean there is a discharge plan in place and that the patient has discussed it with the hospital staff before leaving the hospital.

This should not be done in a hurry, for example, the last three minutes before the patient is discharged. It is important to go over all instructions and answer any questions the patient wants to ask. The plan should be discussed with the patient and family members, if the patient allows them to participate.

Medication Education

Helping the patient understand the medications being prescribed, what each one does and how it should be taken can go a long way in allowing patients to heal at home. While still in the hospital the patient and a healthcare employee should go over each new medication, how it interacts with any other medications, what the patient can expect, and how often the patient should take it. In addition, if the hospital has a good working relationship with a local pharmacist of a hospital pharmacy on the premises, the patient's discharge paperwork should include the pharmacist's name, number and location.

Follow Up is Easy with Cortex CheckUp Calls

By and large having patients recover at home whenever possible is the best scenario in most cases. It relieves any overcrowding, is less expensive both to the patient and the healthcare system, and allows patients to be in their familiar habitats, with friends and family, which is typically good for recovery.

However, it is also important to check up on your clients and make sure they're recovering appropriately during the the first 30 days and thereafter. Cortex offers patient follow-up calls all along the care continuum. Whether you're a hospital, skilled nursing facility or home health agency, you can improve outcomes and reduce readmissions by checking in with your patients regularly. By developing and consistently applying the steps and principles of the discharge and home healthcare plan your chances of readmission is greatly reduced and patients recover more successfully.

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