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20:28:13
Part
III
Observation Medicine
12:22:52
Part III
Chapter
16
New Developments in Observation Medicine
Extended and Complex Observation
L. Christine Gilmore, MD
Bret A. Nicks, MD, MHA, FACEP
Key Points:
Limited literature on approach to extended or
complex observation
Consider combining/modifying existing
protocols for increased complexity
Patients improving but requiring additional
time may benefit from extended observation
Robust quality improvement (QI) program
essential to achieve high-quality and efficient
patient care
Background
Observation medicine (OM) originated over three
decades ago to meet many pressing health care
issues. While improved diagnostic evaluation,
short-term therapy of many emergent conditions,
and enhanced quality and cost containment
remain at the forefront today, the expanding role
of OM continues – and has become an integral
component of Emergency Medicine (EM). In
many parts of the world, Emergency Departments
(EDs) strain to accommodate increasing patient
volumes with more complex illness with the concurrent decrease in overall inpatient bed capacity.
1
At the same time, operati onal and quality
care metrics continue to increase, reflecting the
importance of healthcare delivery and transitions
of care through the entire care process. With
ongoing scrutiny and potential penalties for
short-stay hospital admissions versus observation,
hospitals are incentivized to maximize efficiency
and avoid unne cessary inpatient admissions.
2
In
this shifting milieu of patient care, the growth of
observation services has been notable.
3
Protocols
abound for successful management of increasingly
diverse conditions in the single-disease-focused
observation patient. However, the process of caring
for complex or extended observation patients is
less well defined. Resource utilization issues, however, are unlikely to abate, and observation unit
(OU) providers may be asked to extend the care
opportunities for patients who do not fit the wellestablished protocols.
Streamlined, evidence-based protocols encourage efficiency in the Emergency Department
Observation Unit (ED OU); careful patient selection is mandatory. The approach is characterized
by focused care for a patient requiring 6 to 24
hours of low-intensity treatment or diagnostic
interventions before definitive disposition.
4
The
operational and economic value of observation
has been demonstrated in these patients with a
single problem, such as low-risk chest pain, asthma
or pediatric croup.
5–8
Virtually no literature describes an ED OU
approach when the clinical picture cannot be
similarly reduced. Realdi et al. described a “Rapid
Intense Observation” unit (RIO) for management
of complex patients.
9
The authors used broad
admission criteria; all acutely ill patients were eligible with exceptions of marked clinical instability,
immediate subspecialty needs, residential or social
care issues or severe behavioral disturbances.
In many ways, the Italian RIO approach is similar
to American ED OUs, with clear clinical pathways
and protocols employed to expedite care and optimize efficiency. Initial emphasis is on ruling out
emergency conditions with subsequent diagnosis
or treatment of acute maladies. Similar to ED
OUs, undifferentiated chest pain, syncope, and
arrhythmias were the most common admitting
complaints in the RIO. (See Chapter 21 on Acute
Medicine.) Key differences, however, underscore
the limitations of caring for increasing complexity
in an ED setting. The RIO unit was primarily
managed by Internal Medicine physicians,
rounding multiple times daily, and utilized operational and staffing resources commensurate with
inpatient care. Additionally, the 24-to-72-hour
time frame and 35% admission rate described
under the RIO model exceed the popular ED OU
parameter of a 20% admission rate from the ED
019
20:37:12
OU to hospital inpatient. It is not surprising that,
to date, no literature describes management of a
similarly broad, undifferentiated population in an
ED OU.
Using existing evidence-based protocols in
combination or briefly extending the period of
observation does allow for consideration of more
complex patients with a foundation in the current
literature. While this may allow for expanding
inclusion criteria, maintaining careful patient
selection amenable to evidence-based, protocoldriven care logically preserves the operational
efficiency of the ED OU. Further study is needed
to determine the role and value of observation in
complex patients. In addition to patient outcomes
and operational benefits, changes in staffing,
reimbursement and facility resources – including
actual bed numbers – will require reevaluation as
the scope of OM expand s.
Pathophysiology
Pertinent pathophysiology will vary according to
complaint.
Inclusion criteria
Patients with simple issues that could be successfully managed by combining existing observational protocols may be appropriate for extended
or complex observation. Those with an acute
medical condition in the setting of well-managed
comorbidities may also be appropriate for some
units if otherwise stable. Extended observation
may be considered in patients who are improving
but require a small amount of additional time
beyond 24 hours to meet discharge criteria. These
patients should have a predictable clinical course.
For example, a dehydrated patient with recently
resolved nausea, vomiting and diarrhea could be
stable for discharge if allowed additional time for
correction of electrolyte abnormalities. Social
workers or psychiatric case workers may allow
for ED OU management of patients with complicating psychosocial issues to be addressed before
discharge.
Exclusion Criteria
Those with high acuity, complications, or high
risk of severe illness are likely to need staffing
and services beyond the capacity of an ED OU
and should be admitted to an inpatient hospital
service. A robust resource utilization/quality
assurance (QA)/quality improvement (QI) program is necessary to ensure that complex patients
are being appropriately differentiated from
patient’s with complications prior to ED OU
admission. Patients who will obviously require
beyond 1–2 days stabilizing medical concerns
should be admitted.
Management/Intervention
Management will be similar to traditional patients
with emphasis on communication, reassessment
and quality assurance. Communication is especially important with extended observation
patients, who may be cared for by an increased
number of providers. A formal transfer of care
system should be in place to ensure accurate relay
of medical information through the transitions of
care. Extending observation a few hours may be
useful if it obviates admission, and if quality,
efficiently focused care is provided regardless if
the patient ultimately requires hospitalization.
Although extended observation requires flexibility in length of stay (LOS) benchmarks and a
clearly defined documentation process, admission
criteria should still exclude patients not expected
to improve in the unit. Close attention to maximum LOS and a means for addressing outliers
should be incorporated into the ED OU’s operating policy.
10
Aunit’s need and ability to manage more
complex patients will depend on the staffing
model, ancillary resources, and operational
demands of the institution. Patients with underlying comorbidities may be managed in the ED
OU. When used in combination, protocols may
require modification for the scope of care being
provided, interventions needed, and medi cations
required. Protocols may be used in combination
to manage a patient with a chief complaint and
ancillary issues arising from treatment. For
instance, a hyperglycemia protocol may be used
to treat elevated blood sugar secondary to steroids administered to a patient for a chronic
obstructive p ulmonary disease (COPD) exacerbation. Deconstructing aspects of the presenting
complaint may also allow for management of
greater complexity. Consider cellulitis with
hyperglycemia. A provider might combine cellulitis and hyperglycemia protocols to address a n
elevated blood sugar in a patient with otherwise
L. Christine Gilmore and Bret A. Nicks
019
20:37:12
uncomplicated cellulitis. A retrospective analysis
by Shrock suggests that cellulitis patients with history of diabetes mellitus (DM), typically associated
with a poorer outcome, are not more likely to be
admitted or “fail” observation than those without
DM.
11
Although this was a retrospective analysis,
the article demonstrates several interesting points:
1) There is a need for well-designed, prospective
studies to determine clinical predictors for successful observation management. A recent prospective
study suggests that fraility and sociodemographic
factors significantly impact hospital admission
from an ED OU.
12
2) Clinical predictors may be
useful in revising and expanding admission criteria. 3) Patients with increasing complexity – such
as comorbid DM and cellulitis – may still be
appropriate for OM. Regardless of the nature of
complexity and approach to management, QI/QA
and peer review are essential. Close attention to
patient outcomes is necessary to determine the
success of management involving modification or
combination of existing protocols. (See patient
quality in Chapter 9 on Metrics and Performance.)
An ED OU is often institution specific and
reflects its needs and culture. Observation protocols, patient admissions, care pathways and
staffing models require buy-in from all shareholders including hospital administration, physicians,
nursing and support staff. Units with a limited
number of simple, protocol-driven pathways
might be effectively staffed by midlevel providers
with MD oversight and rounding. Units incorporating complex pathways and conditions, however,
might require more extensive physician staffing.
Avoiding unnecessary admissions, freeing inpatient beds and expediting ED throughput may
justify the expanded staffing model in a busy
urban center – however, this may be more problematic in smaller settings with less volume. (See
Chapter 10 on Community Hospital Perspective.)
Similarly, some health systems or hospitals may
choose to subsidize groups staffing ED OUs in
exchange for operational benefits gained by
expanding the OU. It is important to address
goals of the ED OU as well as reimbursement
with all interested parties before altering the scope
of care. Nurses, pharmacists and ancillary staff
should be considered in these discussions.
Finally, appropriate facilities and equipment
should be available. Beds approved for 23-hour
use only should be upgraded to inpatient standards if extended observation is to be considered.
Dietary services should be available. Any additional pharmaceutical or medical equipment
needs should also be assessed prior to expanding
admission criteria.
Summary
OM is expanding towards the uncharted realm of
caring for complex patients. More research into
the need for, value of and outcomes in caring for
these patients is needed. The low-intensity, shortterm focused care provided by the ED OU may be
extended to patients with greater complexity by
modifying or combining protocols. In some facilities with high volumes or important resource
utilization issues, units may consider increasing
staffing or working with hospitalists to manage
patients with acute and chronic issues. Reimbursement schemes, group and institutional buyin and staffing needs are vital considerations.
References
1. Kellermann AL. Crisis in
the emergency department.
N Engl J Med. 2006;355
(13):1300–1303.
2. Zenner P, Mattie L, Zaharias K.
Recovery audit contractor
(RAC) basics. 2008; 24.
Available: http://
publications.milliman.com/
research/health-rr/pdfs/
recovery-audit-contractorbasics-RR11-01–08.pdf.
Accessed February 2016.
3. Venkatesh A. ED Observation
Units lower health care costs.
Available: www.emra.org/
emra_articles.aspx?id=42328.
Accessed February 2012.
4. Graff LG. Observation
medicine: The healthcare
system’s tincture of time. ACEP,
2009;24. Available: www
.acep.org/WorkArea/Download
Asset.aspx?id=45885. Accessed
February 2012.
5. McDermott MF, Murphy DG,
Zalenski RJ, et al.
A comparison between
emergency diagnostic and
treatment unit and inpatient
care in the management of
acute asthma. Arch Intern Med.
1997;157:2055–2062.
6. Roberts RR, Zalenski RJ,
Mensah EK, et al. Costs of an
emergency department-based
accelerated diagnostic protocol
vs hospitalization in patients
with chest pain: a randomized
controlled trial. JAMA.
1997;278:1670–1676.
Extended and Complex Observation
019
20:37:12
7. Goodacre S, Nicholl J, Dixon S.
Randomised controlled trial
and economic evaluation of a
chest pain observation unit
compared with routine care.
BMJ. 2004;328:254.
8. Greenberg RA, Dudley NC,
Rittichier KK. A reduction in
hospitalization, length of stay,
and hospital charges for croup
with the institution of a
pediatric observation unit.
Am J Emerg Med. 2006;24:
818–821.
9. Realdi G, Giannini S, Fioretto
P, et al. Diagnostic pathways of
the complex patients: rapid
intensive observation in an
Acute Medical Unit. Intern
Emerg Med. 2011;6(1):85–92.
10. ACEP Clinical and Practice
Management. Emergency
Department Observation
Services. Revised and approved
by the ACEP Board of Directors
January 2008. www.acep.org/
content.aspx?id=29204.
Accessed February 2012.
11. Schrock J, Laskey S, Cydulka,
R. Predicting observation unit
treatment failures in patients
with skin and soft tissue
infections. Int J Emerg Med.
June 2008; 1(2):85–90.
12. Zdradzinski MJ, Phelan MP,
Mace SE. Impact of fraility and
sociodemographic factors on
hospital admission from an
emergency department
observation unit. AJMQ
(accepted for publication
2016)
L. Christine Gilmore and Bret A. Nicks
019
20:37:12
Part III
Chapter
17
New Developments in Observation Medicine
Extended Observation Services
Catherine T. Puetz, MD, FACEP
The use of short-stay units for observing patients
as an alternative to hospitalization dates back to
1972.
1
Observation Units (OUs) have emerged as
a viable solution to hospitals facing emergency
department (ED) overcrowding, lack of available
inpatient beds, and the movement by the Centers
for Medicare and Medicaid Services (CMS) and
other third-party payers to expand the list of
treatments and procedures considered as outpatient services.
OUs have allowed physicians to provide better
care in a shorter time period at a decreased cost
to hospitals. Observation care begins after it is
determined by the ED that the patient is unsafe
to go home based on his or her medical condition
and requires more time to determine the need
for inpatient admission or discharge. The time
frame for observation services is a minimum of
8 hours to no greater than 48 hours unless there
are unforeseen medical circumstances that would
require this. The typical observation patient
length of stay is < 23 hours. In the past, CMS
limited the diagnosis list to chest pain, asthma,
and congestive heart failure (CHF). However, this
changed a few years ago when the payment for
observation services would cover all conditions.
2
With these changes, Medicare claims data indicated a trend for more observation services
extending beyond 48 hours from 3% in 2006 to
6% in 2008.
3
These statistics are concerning for
two reasons: first being the fact that Medicare and
private third-party payers will not reimburse hospitals after 48 hours in observation and second
the financial burden an extended observation stay
has on Medi care beneficiaries. These beneficiaries
are subjecte d to higher co-pays and are more
likely to be impacted by the CMS rules regarding
self-administered medications. Being cognizant of
these barriers still doesn’t resolve the problem
OUs face in the 48th hour: what to do with those
patients still categorized as observation status and
not safe for discharge.
Unfortunately, there is very little research to
demonstrate that keeping patients in a dedicated
OU beyond 23 hours is still more cost-effective
when considering the other options such as transferring a patient categorized as observation status
to an inpatient bed
4
or discharging the patient to
an unsafe environment. The OU at my institution
is a 25-bed unit that manages observation status
patients up to 48 hours and longer if needed.
Those of us intimately involved in the development of the OU for our organization were well
aware of the barriers that existed and we have
developed a system that provides efficient comprehensive medical care, addresses patient’s needs
for safe discharge, addresses financial concerns
from the moment they are placed in observation,
and provides 24-hour access for utilization management to readdress a patient’s status as mandated by Medicare beneficiaries patient rights.
The flow of our unit begins with the decision
from the ED provider that the patient is unable to
be safely discharged from the ED due to his or her
underlying medical issue. If the patient’s condition fits the criteria of one of the preestablished
observation diagnosis a “transfer to observation”
order is placed, the observation care set orders for
that specific condition are initiated and the
patient will be moved to the separate medical
OU. It has been clearly established that one of
the reasons ED OUs are so successful is that clear
inclusion/exclusion criteria exist and goals of
observation stays are already in place for staff to
follow.
5
(See Chapters 82–87.) The problem
remains that there are patients that require further observation who don’t fit the preexisting
criteria but still only meet observation status.
Most hospitals utilize the Milliman or InterQual
criteria to determine patient status. These criteria
are complex to understand; at my institution, we
utilize our Patient Placement Department to assist
the ED in assigning the correct status at the time a
bed is requested. After the review is complete and
020
20:37:14
the status is determined to be observation this
patient subset will be transferred to the medical
OU for further care. We have discovered that with
the recent changes in shifting more care to outpatient services, our patient population is older and
our length of stay has increased. We are currently
in the midst of collecting this data and therefore
it is not currently available. However, a recent
study indicates that fraility and sociodemographic
factors, but not age, are significant predictors of
inpatient admission from the observation unit.
6
The processes that we have set in place to help
facilitate care have helped streamline care and we
are very careful to educate our Medicare patients
about their status and the impact it has on them
financially. All patients that are transferred to
the medical OU are notified of their status and
what that means regarding co-pays and the selfadministration of medications. We require all of
our patients to read the information sheet of what
it means to be in observation and we have them
sign the form indicating their understanding of
the process. A copy of the agreement is left with
the patient and a copy is included in the medical
record.
Our approach to observation care is that of a
comprehensive team. Our team consists of observation specific nurses, acute care midlevel providers (PAs, NPs), physicians, care management,
utilization management, environmental services,
PT/OT and pharmacy. Each day begins with a
checkpoint where the plan of care is discussed
amongst the team. It is at these meetings, where
we have utilization management review the patient
to determine if the patient meets inpatient status
or not. Those patients that meet inpatient criteria
are admitted to the hospitalist service in an inpatient bed. For those patients who don’t meet inpatient criteria, the goals of their stay are discussed
as well as some of the outpatient and home needs
that they may require. The care management staff
meets with every patient in the OU a minimum
of once but often more times to discuss financial
concerns, care coordination issues, and health care
access. The team works with families regarding
financial concerns and Medicare-related issues.
The availability of reassessing patient status is
24/7 in our organization, making it easier for us
to keep our commitment to assign the correct
status to the patient as his or her medical condition indicates.
Our organization accepts the fact that the
aging population and their increased medical
needs will result in longer observati on stays due
to medical necessity. The observation services
provided in the dedicated OU unit of our organization are safe and efficient for our patients
leading to desirable outcomes for the patient and
the organization.
Hopefully, the Acute Care Organizations
(ACOs) will recognize that with the ever growing
elderly population and the trend towards more
complex services being provided as an outpatient,
the need for extended observation stays is inevitable and the use of ED OUs for the care of these
patients is still more cost-effective than having
these patients placed in an inpatient bed. (See
Chapter 20 on ACOs.)
References
1. Gururaj VJ, Allen JE, Russo
RM. Short stay in an outpatient
department: An alternative to
hospitalization. Am J Dis Child
1972; 123:128–132.
2. Hale DK. Observation Status:
A Guide to Compliant Level
of Care Determination,
Second Edition. HC Pro, Inc.
2008.
3. ClarkC.AHA:Observation
Status Fears on the Rise. Health
Leaders Media. October 29, 2010.
4. Ross MA, Compton S,
Richardson D, et al. The use and
effectiveness of an emergency
department observation unit for
elderly patients. Ann Emerg
Med 2003; 41(5):668–677.
5. Koenig BO, Ross MA, Jackson
RE. An emergency department
observation unit protocol for
acute-onset atrial fibrillation is
feasible. Ann Emerg Med 2002;
39:374–381.
6. Zdradzinski MJ, Phelan MP,
Mace SE. Impact of fraility and
sociodemographic factors on
hospital admission from an
emergency department
observation unit. AJMQ
(accepted for publication 2016).
Catherine T. Puetz
020
20:37:14
Part III
Chapter
18
New Developments in Observation Medicine
Hospital Readmissions
Sharon E. Mace, MD, FACEP, FAAP
Overview
Hospital readmissions are not only common but
also costly.
1
They have become a key focus in
health care. In the United States, approximately
20% of Medicare beneficiaries are readmitted to
the hospital within 30 days of discharge.
1
More-
over, the estimated cost of these readmissions is
17.4 billion dollars per year.
1
Therefore, it should
not be a surprise that hospital readmissions are
being scrutinized in an effort to decrease hospital
readmissions and costs. Evidence of this intense
scrutiny is demonstrated by the increasing use of
hospital readmissions for public reporting and
pay-for-performance.
2,3
In the United States, the Centers for Medicare
and Medicaid Services (CMS) and the Veterans
Health Administration (VHA) publicly report
30-day readmission rates for three medical conditions: heart failure, pneumonia and acute myocardial infarction (MI).
4,5
CMS reduces Medicare
reimbursements to hospitals that have excessive
readmission rates of these three conditions.
6
The
most expensive Diagnosis-Related Group (DRG)
diagnosis for hospitalizations in general and the
most frequent diagnosis for 30-day readmissions
is heart failure with a cost of 15 billion in the
United States.
7
Moreover, CMS intends to expand its readmission program that penalizes hospitals with excessive readmission rates to include surgical
procedures in addition to the three medical conditions: heart failure, pneumonia and acute MI.
6,8
Decreasing readmission rates has become a
national priority. As mentioned, CMS publicly
reports these rates. The National Quality Forum
(NQF) has endorsed hospital risk-standardized
readmission rates (RSRRs) as performance measures, with specific endorsed measures: RSRR for
heart failure, acute MI (AMI), elective primary
total hip arthroplasty (THA) and total knee arthroplasty (TKA).
8
Recently, the Patient Protection
Affordable Care Act of 2010 created new financial
incentives for reducing readmission rates using the
publicly reported measures.
9
By 2015, hospitals
with high readmission rates can lose ≤ 3% of their
Medicare reimbursement.
10
This financial impetus
has led to many initiatives at all levels: local, state
and national, which will be discussed as potential
solutions to the readmissions dilemma.
Rates of 30-Day Readmissions
Not all readmissions are preventable or avoidable.
3,11
Moreover, the incidence of 30-day of
“preventable or avoidable readmissions” varies
greatly.
11
Often quoted percentages of prevent-
able admissions are in the 18% or 20% range.
1,2
However, rates up to as high as 47% or even 59%
in studies that used only adm inistrati ve data
have been reported.
12,13
The incidence of avoidable readmission rates was as low as 9.3% to a
high of 39.9% of all readmissions, according to
one meta-analysis, dependi ng at least in part on
the method utilized to determine if the readmission was preventable (e.g., on the number of
reviewers).
14
Should 30-Day Readmissions Be Used
as a Metric?
Some experts have questioned the use of 30-day
readmissions as a metric.
11–18
A prospective multicenter study found that the methodology used to
determine readmissions can greatly affect the
readmission rate. They found that the readmission rates “cannot be determined accurately on
the basis of administrative data alone” and “is
a subjective judgment that requires detailed
patient data, multiple reviewers and an analysis
that accounts for differing reviewer accuracy
when collating judgments.” They concluded that
“urgent readmissions should be used with caution
to gauge the quality of hospital care.”
15
021
20:37:32
Others have also echoed these sentiments.
“Readmission rates are not a reliable measure of
hospital quality in cardiac surgery.”
16
“Most
readmissions a t our public, safety net hospital
were unavoidable” and “these findings suggest
that readmissions do not necessarily reflect inadequate medical care, may reflect resource constraints that are unlikely to be addressable in
systems caring for a large burden of uninsured
patients, and merit individualized review.”
17
Several problems with using 30-day readmis-
sions as a metric have been noted.
11
These reasons
include the following: only a small percentage of
readmissions at 30 days are preventable, the majority of variables that determine hospital readmission
rates are “patient- and community-level factors
that are well outside the hospital’s control,” and
high admission rates could be “the result of low
mortality rates or good access to hospital care.”
Furthermore, they cite other unforeseen consequences of using the 30-day readmission rate: in
their zeal to reduce readmission rates, hospitals are
bypassing other “more urgent issues, such as
patient safety” and there are “better, more targeted
policies” that will improve discharge planning and
care coordination.
11
Some readmissions may be “unavoidable” or
“not preventable” and/or are outside the purview
of the hospital.
11–18
The “socioeconomic dispar-
ities in readmission raises the question of whether
CMS’s readmission measures and associated
financial penalties should be adjusted for the
effects of factors beyond hospital influence at the
individual or neighborhood level, such as poverty
and lack of social support.”
18
This is because all-
cause readmission statist ics “are only partially
influenced by quality of care.”
14
International Perspective
It should be noted that this emphasis on readmissions is not unique to the United States, but is a
worldwide issue with varying but somewhat similar 30-day readmission rates (16.0%, 16.7%) and
similar risk factors, specifically increased illness
severity as denoted by longer hospital stay,
comorbidity (e.g., active malignancy, anemia),
and higher Charlson scores, which are all associated with increased readmission rates.
15,19–21
Report to Congress
In a report to Congress, “Payment Policy for
Inpatient Readmissions,” the recommendations
for ways for hospitals to reduce readmissions were
“provide better, safer care during the inpatient
stay,”“attend to patient’s medication needs at dis-
charge,”“improve communication with patients
before and after discharge,”“improve communi-
cation with other providers” and “review practice
patterns.”
2
(Table 18.1) There has been literature
evaluating these recommendations and suggested
methods for their implementation, which will be
addressed in the sections to follow.
Patient Disease/Illness/Injury Factors
The factors contributing to 30-day readmissions are
just beginning to be elucidated, but some variables
have been identified. (Table 18.2) Many of the
factors can be correlated with the patient’s disease
or clinical condition, especially the severity of their
disease.
22
Prior admissions,
23–26
need for medica-
tions, such as chronic steroid use,
27,28
and new need
for home oxygen
29
may be markers for significant
underlying chronic illnesses/diseases and have been
associated with increased readmission rates. Significant comorbidity – including kidney injury, renal
failure, dialysis, cardiovascular disease including
heart failure, immunosuppression, bleeding
disorders (including those from anticoagulant and
other therapies), diabetes, anemia and AIDS –
have been noted to increase the risk of readmission.
25,28–36
An increased number of comorbidities
or a higher Charlson score are also associated with
increased readmission rates.
24,26,29,37,38
Psychiatric
illnesses/mental health comorbidities
39,40
and
dementia
41
have been linked to an increased risk
of 30-day readmissions.
Prolonged length of stay (LOS) and intensive
care unit (ICU) admission as indicators of severity of disease have been linked to increased 30-day
Table 18.1: Recommendations for How Hospitals Can
Reduce Readmissions*
- Provide better, safer care during the
inpatient stay
- Attend to patient’s medication needs at
discharge
- Improve communication with patients before
and after discharge
- Improve communication with other providers
- Review practice patterns
* From “Payment Policy for Inpatient Readmissions” from
www.medpac.gov/documents/Jun07_EntireReport.pdf.
Sharon E. Mace
021
20:37:32
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