The campaign calls upon hospitals and others in the care continuum to focus on five key areas known to reduce avoidable readmissions. By implementing and spreading these best practices, hospitals can become more effective, more rapidly, in reducing avoidable readmissions. Through the RARE Campaign, hospitals can choose to work on any of the following five key areas:
- Comprehensive discharge planning – Focus on ensuring that all of a patient’s needs are considered and included in a comprehensive discharge plan with input from the patient and family. Interventions may consist of written, visual or recorded discharge plans that include and consider follow-up appointments, medications, nutritional needs, family support, transportation, health literacy, knowing whom to call, social problems, and red flags.
- Medication management – Focus on improving the use of medications for the patient’s condition and ensuring that the patient understands the purpose of the medications and is taking them in the correct manner at the correct time. Interventions may include medication reconciliation, patient/family education on medications, medication therapy management, and medication set-up simulations for the patient/family.
- Patient and family engagement – Focus on ensuring that processes are in place to engage patients/family, elevate the status of family caregivers as essential members of the team, and prepare the patient and family to manage care at home. Interventions may include such methodologies as teach back, collaborative conversations and communication, and simulations with the patient and family member.
- Transition care support– Focus on ensuring that transition plans are in place and followed so that the patient’s care is coordinated between one caregiver and another. Interventions may include the role of care coach, transition coordinator and post-transition follow-up care.
- Transition communications – Focus on ensuring that effective communication occurs between sending and receiving care givers working with the hospital, e.g., home care, home, primary/specialty care, skilled nursing facility or rehab. Interventions may include processes for transferring information, providing discharge summaries in a timely manner, defining accountability for care, communication of the plan of care, methods for talking directly with sending or receiving caregivers, definition of key information which may include current health status, follow-up needs, pending test results, red flags, medications and special patient needs.
Patients who are readmitted
Hospital readmissions are the result of the fragmentation that plagues the health care system. Patients are readmitted because of:
- Inadequate information and preparation for post-discharge care and self-care.
- Poor transmission of hospital records and discharge instructions to primary care clinicians who manage post-discharge recovery or to organizations which authorize or provide post-discharge care.
- Untimely and uncoordinated post-hospital care in their community.
- Preventable medical errors/complications during the first hospital stay.
The highest rates of readmitted patients:
- Have heart failure, chronic obstructive pulmonary disease (COPD), psychoses, intestinal problems, and/or have had various types of surgery (cardiac, joint replacement, or bariatric procedures).
- Take six or more medications, have depression and/or poor cognitive function, and/or have been hospitalized in the previous six months.
- Are discharged on weekends and holidays.