A study published in the New England Journal of Medicine last year found that nearly one fifth of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days, and 34 percent were rehospitalized within 90 days. A 2005 analysis by the federal Medicare Payment Advisory Commission (MedPAC) concluded that as many as three out of four 30-day readmissions may be preventable.
Improving transitions of care, as patients move between health care settings or go home, has been identified as a key way to reduce rehospitalizations. One of the opportunities to improve transitions involves streamlining communication and care coordination between acute care hospitalists and the community primary care physicians and specialists involved in the care management of the chronic, comorbid patient population. Coordination of post acute follow-up care with primary care physicians within seven days of discharge, medication reconciliation and support of patient/caregiver selfmanagement skills all impact prevention of avoidable acute care hospitalizations. All of these causes can be addressed through care transition improvement. Read the rest of this entry »