Lowering Hospital Readmission Rates



Mary Proctor, 83 is a DC resident and a widow that lives alone.  Her adult children live out of state, but she loves to travel to visit her kids, as well as her grandkids, and she lives an active life with friends and neighbors.  She is involved in her church and volunteers for numerous charities.

In November of 2017, Mary suffered a mild stroke, also known as a TIA, and was rushed to a local hospital where her condition was stabilized.  She spent five days in the hospital and was released with two new medications to help her continue her recovery and prevent future strokes. Her doctors also prescribed physical therapy and occupational therapy due to some weakness on her left side.  

Her daughter had flown in from California the day before Mary was released from the hospital to help her transition home.  On the day Mary was released her daughter stopped by the hospital pharmacy to pick up her new medications and then drove Mary home.  Mary’s daughter got her settled in at home and then went to the local Safeway to pick up fresh food and refills of the four medications Mary had been on for the last few years prescribed by her family doctor.  

Two days later, Mary was in the emergency room having suffered an adverse reaction to the combination of medications she had always been taking with the new medications she was prescribed at the hospital.  This time she spent 6 days in the hospital, followed by 2 weeks in a skilled nursing facility to help her recover and regain her strength.

Factors That Impact Hospital Readmission Rates

This scenario is all too common.  According to the Center for Medicaid and Medicare Services (CMS), nearly 20% of patients discharged from a hospital are readmitted within 30 days and it is estimated that almost two thirds of those readmissions are preventable.  

According to a Yale Study, there are four main factors that influence the probability of readmission:

  • The patient’s ability to understand their plan of care
  • Medication adherence and mixtures
  • Follow up appointments with their primary care physician within two weeks of discharge
  • Family and/or caregiver support at home

For Mary, it was a case of medicine mixtures.  The hospital was not aware of the medications Mary was previously prescribed, and Mary’s daughter picked up medications from two different pharmacies, which prevented the pharmacists from catching the adverse reaction risk.  

Georgetown Home Care’s Hospital Readmissions Reduction Program

Care needs to be approached holistically, otherwise these types of preventable hospital readmissions will continue to occur. Establishing and implementing procedures that continuously evaluate the main causes of hospital readmission, will greatly improve the patient’s quality of life and the provider’s care outcomes.

At Georgetown Home Care, we have studied the U.S. readmission problem closely and have developed our own practices to help mitigate unnecessary readmission rates in our client population.  We closely monitor medication, review the hospital plan of care with each new client to make sure they understand and have the ability to follow it, in addition we encourage visits to primary care physicians immediately after discharge from a hospital or skilled nursing facility.  

We closely track our 30-day readmission rates among our clients.  We are very pleased to report our 2017 readmission rate is just 7.6 percent. The national hospital readmission rate is currently 15.3 percent and the national home health care admission rate is 16.3 percent.

National Hospital Readmission Rates

Home Care readmission rates are not currently tracked on a notional level, but our considerably lower hospital readmission rate is not something we take lightly. We recognize that too many people are going to the hospital when a visit is not necessary, putting a strain on the entire healthcare system.

Georgetown Home Care feels that every player in a patient focused, value based health care system has a role to play in making sure all entities are being used efficiently and effectively to provide the best care for the patient.

Georgetown Home Care is committed to lowering readmission rates across our community.  We have been teaching continuing education classes to social workers, Registered Nurses at hospitals and skilled nursing facilities for over three years. We have also partnered with forward thinking facilities in the area to discover better procedures and programs for safe and effective transitions of care.  

Our goal is to drive preventable readmission rates for us and our partners down to zero and we will continue to seek ways in which to do so.  

Learn more about our Welcome Home Program