How to Break the Cycle of Readmission in Hospitals 

Hospital readmissions are one of the key metrics used for evaluating the quality of patient care. High recidivism rates often lead to poorer patient outcomes and higher out-of-pocket costs. It can result in stiff penalties for hospitals and reduced Medicare funding, while taking a toll on already overburdened nursing staff, leading to increased burnout. This can create a vicious cycle where the workload gets heavier and more nurses leave the profession, making it even harder to provide safe and effective care. Yet, studies show that with the right transition plan and patient support, recidivism rates can improve, which is a win for both patients, providers and nurses.  

The Troubling Cost of Readmission Rates 

Today, the average readmission rate hovers around 15%, which may sound manageable. But, at an average cost of $16,300 per readmission, this can quickly add up.  

In 2018, this amounted to $3.49 billion in additional healthcare costs, and when you consider that readmissions are often 12% higher than the cost of “index” or initial hospitalizations, there’s a compelling reason to keep readmission rates low. 

Medicare funding is also tied to readmission rates. The Patient Protection and Affordable Care Act of 2010 made several payment reforms to address this problem, with the Hospital Readmissions Reduction Program introduced in 2012, which financially penalizes hospitals with above-average readmission rates.  

Within ten years of implementation, over 2,600 hospitals had a portion of their annual Medicare reimbursements withheld, which can contribute to worsening budget deficits and the inability to recruit new staff to maintain critical nurse-to-patient ratios.  

A Toll on Patients 

The most troubling toll is the effect on patient health. One study found that nearly 20% of patients experience adverse events within 3 weeks of hospital discharge, which can include adverse reactions to new medications and post-surgical complications.  

More disturbing is that nearly 40% of patients are discharged with test results pending or diagnostic work that must be completed as an outpatient, placing the onus on patients and their families to ensure proper follow-up care.  

Many patients are also discharged without adequate education. Even when discharge instructions are provided, they are commonly misunderstood, especially among patients with low health literacy and no support at home.  

This can be worsened by a lack of timely communication between inpatient hospital staff and family physicians, leading to disjointed care and critical follow-ups that could be missed. Without proper diagnostic testing (including post-discharge lab tests and imaging), comprehensive patient education, and reconciliation with current prescriptions, patients are vulnerable to worsening conditions, hospital readmissions, and even higher mortality rates.  

The Impact on Hospital Staff 

This negative impact on patient health, in turn, affects hospital staff. Frequent readmissions lead to higher patient loads and more complex discharges. It can overburden hospital nurses, leading to feelings of helplessness, frustration, and moral distress, as well as decreased job satisfaction.  

While Medicare penalties from high recidivism rates can eat into already strained healthcare budgets, leading to understaffed hospitals and higher overall workloads, causing record rates of staff burnout.  

Surveys of nursing professionals show that over 40% are already burnt out and are considering early retirement or may simply leave the profession over the next 5 years. Inadequate staffing even affects nurses’ ability to detect complications and implement preventive measures that could reduce readmissions.  

It’s a vicious cycle where poor patient outcomes weigh heavily on nursing staff, who are the primary surveillance system in hospitals. When that surveillance system is compromised because of retention issues and understaffing, as well as low morale, nurses are unable to act on patient conditions, impeding their ability to provide comprehensive care. 

Are Readmissions Avoidable? 

While readmissions aren’t entirely avoidable, the sobering fact is that almost 30% are potentially preventable with the right combination of patient education, follow-up, and structured communication between healthcare providers and patients. Yet, currently, half of those who end up readmitted receive no clinician follow-up within 30 days of their initial hospital discharge.  

Many studies show that follow-up care is critical if we want to keep recidivism rates low. One example is the Care Transitions Intervention (CTI) program in Colorado where older patients received a care transition plan that included at least 3 phone calls within 28 days of hospital discharge, as well as a dedicated nurse transition coach who ensured timely follow-ups, educated patients about proper self-care and made sure patients knew what to do if a problem arose. This multifaceted intervention resulted in a 3.6% reduction rate in 30-day readmissions, and a 5.8% reduction rate in 90-day readmissions, with cost savings of $375,000 or about $500 per patient.  

Another study followed patients discharged from U.S. hospitals with heart failure, acute myocardial infarction (AMI), COPD, or stroke, and saw a 21% reduction in risk of readmission when outpatient follow-up was conducted shortly after hospital discharge. 

How itel Med Can Support Better Patient Transitions and Outcomes 

itel Med solutions can play a pivotal role in reducing readmissions through a focus on smoother transitions of care, enhanced patient education, and a discharge strategy that includes regular telehealth check-ins and ongoing support.  

Our licensed telehealth nurses work as an extension of your team to fill the gaps on critical processes. Through a secure video platform, itel Med supports patient questions, with the ability to review newly prescribed medications and go over post-discharge instructions, to ensure optimal patient outcomes.  

Readmission risk can be reduced by educating patients about post-op recovery and how to prevent complications and infections. Our nurses can also coordinate outpatient labs and testing, as well as liaison with physicians to ensure timely patient follow-ups and appointment scheduling. 

This targeted support can help hospital systems avoid costly readmission penalties, improve patient outcomes, and give your clinical team more time to focus on delivering quality inpatient care, breaking the cycle of recidivism that can otherwise take a heavy toll on both patients and the nursing workforce. 

Learn more about itel Med and how we can help break the cycle.