CAYC

Improving Care Transitions, Reducing Avoidable Hospital Readmissions

There are dangerous gaps between the health care people should get and the care they actually do get—especially in the treatment of chronic conditions that affect millions, such as asthma, diabetes, and heart disease.

Launched in 2011, Care About Your Care focuses attention on what people can do to provide and receive better health care. This Robert Wood Johnson Foundation national initiative focuses on improving care transitions to reduce avoidable hospital readmissions, and how nurses, care coordinators, doctors, consumers, caregivers, patients, and others can work together to achieve this.

The Challenge

The U.S. health care system suffers from a chronic malady—the revolving door syndrome at its hospitals.  It is so bad that the federal government says one in five elderly patients is back in the hospital within 30 days of leaving.

Some return trips are predictable elements of a treatment plan. Others are unplanned but difficult to prevent: patients go home, new and unexpected problems arise, and they require an immediate trip back to the hospital. But many of these readmissions can and should be prevented. They are the result of a fragmented system of care that too often leaves discharged patients to their own devices, unable to follow instructions they didn’t understand, and not taking medications or getting the necessary follow-up care. The federal government has pegged the cost of readmissions for Medicare patients alone at $26 billion annually, and says more than $17 billion of it pays for return trips that need not happen if patients get the right care. This is one reason the Centers for Medicare & Medicaid Services has identified avoidable readmissions as one of the leading problems facing the U.S. health care system and now penalizes hospitals with high rates of readmissions for their heart failure, heart attack, and pneumonia patients. 

Potential Solutions

There's more than one path to reducing avoidable readmissions. In communities across the country, doctors, nurses, hospitals, care facilities, and community organizations are working with patients to stop the revolving door of avoidable readmissions for good.

Continuing Education for Physicians and Nurses

Through this program we are offering a video series to earn nursing and medical education continuing education credits for learning how to improve care transitions and prevent avoidable hospital readmissions. Learn more

Finding Solutions Together

The Robert Wood Johnson Foundation sponsored the Transitions to Better Care video contest where nurses, care coordinators, physicians and other front-line care team members to shared videos highlighting how they've ensured patients transitioning from the hospital to the home are given and understand comprehensive instructions, and are provided the necessary support and resources to help ensure they remain on a path to wellness. Learn more about their approaches

Provider Toolkit

This toolkit contains resources to help providers reduce avoidable hopsital readmissions by planning for the transition during the inpatient stay, educating the patient on what he/she needs to do after discharge, and helping the patient stay on-track with post care coordination and support. Download the resources

The Revolving Door Syndrome
The Revolving Door Syndrome

The Revolving Door: A Report on U.S. Hospital Readmissions

This report shows that hospitals and their community allies made little progress from 2008 to 2010 at reducing hospital readmissions for elderly patients. The report also chronicles a series of in-depth interviews with patients and providers that shed light on why patients end up back in the hospital and what hospitals, doctors, nurses, and others are doing to limit avoidable readmissions. New Medicare data from the Dartmouth Atlas Project shows that patients’ chances of being readmitted largely depend on where they live and the hospitals where they receive care.

Read the report

A nurse provides discharge instructions to a patient.

Watch the video to learn about innovative solutions from communities across America.

Watch the video to learn about innovative solutions from communities across America.

About This Initiative

CAYC

This RWJF national initiative focuses on improving care transitions to reduce avoidable hospital readmissions, and how nurses, care coordinators, doctors, consumers, caregivers, patients, and others can work together to achieve this.