How Can Physician Practices Help Reduce Hospital Readmissions?

Among the many studies on hospital readmissions, one point that continually emerges and is generally accepted is that the entire healthcare system – from physicians’ offices to hospitals, post-acute providers, home care agencies, and even patients and family caregivers – must work together to reduce a patient’s need to revisit a hospital within 30 days of discharge.
In the current healthcare system, although there is much collaboration to ensure patients progress through the system and receive timely follow-up care, any break in that chain most likely results in a patient returning to the hospital and definitively results in the hospital alone suffering a financial penalty. 
Now, the Agency for Healthcare Research and Quality (AHRQ) has released a report that identifies primary care-based strategies for reducing hospital readmissions.
“Many efforts to reduce readmissions have focused on the hospital setting and staff using evidence-based programs,” AHRQ wrote. “…The evidence-base for the primary care setting on how to reduce readmissions and improve patient safety is comparatively lacking. This gap in the literature is becoming more pronounced as primary care is increasingly called to serve as the key integrator across the health care system as part of payment and delivery system reforms.”
The AHRQ report – essentially an environmental scan on what is currently known about reducing readmissions from the primary care perspective – found that the characteristics of various practices makes it difficult to pinpoint specific things they can do to support effective care transitions. “Primary care may play a small to large role in care transition interventions, and the complexity of these interventions can vary greatly depending on circumstances in their health system environment and relations with other health system members,” AHRQ wrote.
Nonetheless, a key takeaway AHRQ found is that multi-component interventions that addressed multiple challenges of patients and providers tended to be more effective than individual interventions. Also, care transition programs in the context of more general primary care transformation efforts, such as the patient-centered medical home, tended to be more effective.
In Massachusetts, hospitals have been engaged in a variety of efforts to reduce readmissions, most recently in the ongoing Hospital Improvement Innovation Networks (HIIN). MHA is coordinating a 10-hospital HIIN in Massachusetts throughout 2019, the main goal of which is to reduce all-cause inpatient harm by 20% and readmissions by 12%. Other Massachusetts hospitals are participating in a HIIN coordinated by AHA.