Takeaway
A patient’s familiarity with my hospital, even down to memorizing the cafeteria menu, highlighted the urgent need to address the factors driving readmissions. Read on to find out how you can do this in your own practice.
Lifelong Learning in Clinical Excellence | April 15, 2025 | 3 min read
By Kittane “Vishnu” Vishnupriya, MBBS, Johns Hopkins Medicine
“The French toast is always so good here, I love it.” Mrs. K wasn’t referring to her favorite restaurant but actually to the hospital cafeteria that had just delivered breakfast. She’d been readmitted so many times over the last year that she knew the menu by heart and was familiar with all the inpatient protocols all too well. Frequently readmitted for COPD exacerbations, she could say aloud from memory the dose of prednisone that works for her, the need for levalbuterol and saline nebs every four hours, and the details of the prednisone taper she usually ends up getting. She knew some of the staff members by first name and could impress medical students when she could tell them some side effects of medications that they weren’t aware of.
Mrs. K’s frequent readmissions are a common occurrence, with one in five patients who are on Medicare getting readmitted within 30 days of discharge. Millions of patients think of hospitals floors as having revolving doors where discharges only lead to another admission after a few days. This results in tremendous burden on patients and their families and has serious financial penalties and additional costs to healthcare systems. Causes of readmissions are complex, ranging from disease progression, to lack of outpatient follow-up and support, to complex social situations. It’s thought that about one in three of these readmissions are preventable.
Healthcare professionals can do the following to minimize readmissions:
1. Make sure there is excellent communication and handoffs between inpatient providers and outpatient providers. An error free, clearly stated discharge summary with follow-up plans and tests needed sent to the patient’s primary provider can help prevent readmission.
2. Schedule follow-up appointments. Make sure patients have follow-ups with specialists and primary providers in a timely manner post-discharge.
3. Ensure detailed medication reconciliation and clear patient instructions that are understood by the patient and families at time of discharge.
4. Ensure patients are on the best evidence-based therapies for their condition that are known to help reduce readmissions, especially for conditions like congestive heart failure, COPD, CAD, and stroke, to name a few.
5. Focus on hospital acquired conditions that can lead to readmissions, including urinary tract infections, line and wound infections, and pneumonias that need protocol driven multilevel strategies. These also impose financial penalties on hospitals as well as poor patient satisfaction scores.
6. For patients who are both medically and socially complex, there should be a dedicated team of case managers and social workers to help the patient connect with resources that they might not be aware of. This may include resources for transportation, housing, or food, as these are often the underlying causes for readmission.
7. Aggressively screen and treat co-existing mental conditions and any substance abuse that might be contributing to readmissions. Have psychiatry and behavioral health teams round on inpatients that are determined to be high risk based on this screening.
8. Engage early with patients and families in goals of care discussions when there’s evidence of a progressive condition or expected deterioration despite best care.
It’s likely that most hospitals do some or all of the above but are still struggling to reduce readmissions. This doesn’t mean these efforts are futile. Reducing readmissions is going to be a constant ongoing effort. Hospitals should engage staff at all levels and encourage implementation of QI and patient safety programs that are owned and driven by frontline staff.Recognizing these efforts can be impactful and create a culture of constant learning and improvement.
I thanked Mrs. K for her kind words regarding the food and was also determined to run through everything on the above list in my mind and to make sure my team wasn’t missing anything. But first, to help connect with her, I texted my wife who is a foodie to find out what makes a French toast taste great.
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This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.