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<script type="text/javascript" src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.boots.min.js"> </script><title>Reducing Hospital Readmissions - StatPearls - NCBI Bookshelf</title>
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<meta name="citation_title" content="Reducing Hospital Readmissions">
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<meta name="citation_date" content="2024/06/07">
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<meta name="citation_author" content="Jasninder S. Dhaliwal">
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<meta name="citation_author" content="Ashujot Kaur Dang">
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<meta name="citation_pmid" content="39163436">
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<meta name="DC.Contributor" content="Ashujot Kaur Dang">
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</svg> Books</a></div><div class="jr-rhead f1 flexh"><div class="head"></div><div class="body"><div class="t">Reducing Hospital Readmissions</div><div class="j">StatPearls [Internet]</div></div><div class="tail"></div></div><div id="jr-tb2"><a id="jr-bkhelp-sw" class="btn wsprkl hidden" title="Help with NLM PubReader">?</a><a id="jr-help-sw" class="btn wsprkl hidden" title="Settings and typography in NLM PubReader"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512" preserveAspectRatio="none"><path d="M462,283.742v-55.485l-29.981-10.662c-11.431-4.065-20.628-12.794-25.274-24.001 c-0.002-0.004-0.004-0.009-0.006-0.013c-4.659-11.235-4.333-23.918,0.889-34.903l13.653-28.724l-39.234-39.234l-28.72,13.652 c-10.979,5.219-23.68,5.546-34.908,0.889c-0.005-0.002-0.01-0.003-0.014-0.005c-11.215-4.65-19.933-13.834-24-25.273L283.741,50 h-55.484l-10.662,29.981c-4.065,11.431-12.794,20.627-24.001,25.274c-0.005,0.002-0.009,0.004-0.014,0.005 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Readmissions</span></h1><p class="contribs">Dhaliwal JS, Dang AK.</p><p class="fm-aai"><a href="#_NBK606114_pubdet_">Publication Details</a></p></div></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="article-155646.s1"><h2 id="_article-155646_s1_">Summary / Explanation</h2><p>
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<b>Introduction</b>
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</p><p>A hospital readmission is when a patient discharged from the hospital is readmitted within a specified time frame. Various time frames have been used, but the most common are 30-day (Medicare definition), 90-day, and 1-year readmissions. The first hospital stay is termed "index admission," and the subsequent hospital admission is termed "readmission." Hospital readmissions can pose significant challenges for both healthcare providers and patients. Moya Woodside first mentioned hospital readmission in psychiatric patients in 1953.<a class="bibr" href="#article-155646.r1" rid="article-155646.r1">[1]</a><a class="bibr" href="#article-155646.r2" rid="article-155646.r2">[2]</a> Since then, hospital readmission has gained more recognition in medical literature, leading to rising healthcare costs, accounting for billions in costs.<a class="bibr" href="#article-155646.r3" rid="article-155646.r3">[3]</a> This has put a substantial financial burden on the healthcare system. From a statistical perspective, approximately 20% of Medicare beneficiaries experienced readmission within a span of 30 days.<a class="bibr" href="#article-155646.r3" rid="article-155646.r3">[3]</a></p><p>In 2010, hospital readmission rates were formally included in reimbursement decisions by the Centers for Medicare and Medicaid Services (CMS) formally included as part of the Affordable Care Act (ACA). This legislature resulted in the CMS initiating penalties for healthcare systems that exhibited relatively higher rates of readmissions through the Hospital Readmission Reduction Program (HRRP). In 2013, the HRRP was officially introduced and applied to all hospitals except psychiatric, rehabilitation, pediatric, cancer, and critical access hospitals. In recent years, healthcare organizations have actively worked to decrease readmissions by implementing diverse strategies. The readmission rates have been increasingly utilized as a quality benchmark for health systems and an outcome measure in health services research.<a class="bibr" href="#article-155646.r4" rid="article-155646.r4">[4]</a> It has been further explored in health services outcomes research about the patient demographics, frequency, regional differences, their causes, and various methods and models to prevent them.<a class="bibr" href="#article-155646.r5" rid="article-155646.r5">[5]</a><a class="bibr" href="#article-155646.r6" rid="article-155646.r6">[6]</a> </p><p>When patients are readmitted shortly after their initial hospital stay, it indicates suboptimal quality of care, inadequate patient education, and challenges transitioning from hospital to home. In the last decade, more programs have been introduced to reduce hospital readmissions, as this has become a top priority in U.S. healthcare reform. These have significantly reduced the readmission rates to about 15% from 20% in myocardial infarction (AMI) patients.<a class="bibr" href="#article-155646.r7" rid="article-155646.r7">[7]</a> Further studies have shown that readmission rates declined from 21.5% to 17.8% for targeted conditions and 15.3% to 13.1 % for non-targeted conditions in the time period from 2007 to 2015 (per Medicare).<a class="bibr" href="#article-155646.r8" rid="article-155646.r8">[8]</a> In this article, we will delve into the importance of reducing hospital readmissions, the underlying causes of readmissions, and the strategies used to tackle this crucial challenge.</p><p>
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<b>The Significance of Hospital Readmission Reduction</b>
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</p><p>Reducing hospital readmission is crucial for several reasons, as shown below.</p><p>
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<b>Patient Well-Being</b>
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</p><ul><li class="half_rhythm"><div><b>Emotional and physical impact</b>: Frequent hospital readmissions can emotionally drain patients and their families. The stress, uncertainty, and disruption caused by repeated hospital visits can be emotionally draining. Physically, patients may face complications related to their health conditions or treatments.</div></li></ul><ul><li class="half_rhythm"><div><b>Confidence in the healthcare system</b>: Multiple readmissions can erode patients' trust in the healthcare system. They may question the quality of care received during their initial hospital stay and wonder why they need to return so soon.</div></li></ul><p>
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<b>Financial Implications</b>
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</p><ul><li class="half_rhythm"><div><b>Cost to patients</b>: Hospital readmissions often result in out-of-pocket expenses for patients. Copayments, deductibles, and other costs accumulate with each admission.</div></li></ul><ul><li class="half_rhythm"><div><b>Healthcare institutions' costs</b>: Readmissions strain healthcare resources, including hospital beds, staff time, and medical supplies. Hospitals must allocate additional resources to manage these cases.</div></li></ul><ul><li class="half_rhythm"><div><b>Overall Cost of Care</b>: The cumulative cost of readmissions contributes significantly to healthcare expenditures. Reducing readmissions can mitigate this financial burden.</div></li></ul><p>
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<b>Resource Optimization</b>
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</p><ul><li class="half_rhythm"><div><b>Efficient use of resources</b>: When patients are readmitted, it diverts resources from other patients who also need care. By minimizing readmissions, we optimize resource allocation.</div></li></ul><ul><li class="half_rhythm"><div><b>Focus on preventive measures</b>: Efforts to reduce readmissions encourage healthcare providers to focus on preventive strategies. This includes better discharge planning, patient education, and post-discharge follow-up.</div></li></ul><p>
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<b>Reasons Behind Readmissions</b>
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</p><p>Understanding the root causes of hospital readmissions is crucial for developing effective reduction strategies. While numerous readmissions are not preventable, they may represent disease progression, a separate problem unrelated to admission, or difficulties in adhering to the discharge plan (such as being unable to fill prescriptions). Some readmissions are likely preventable; a systematic review of 34 studies revealed that the median proportion of preventable readmissions was 27 percent, ranging from 5 to 79 percent.<a class="bibr" href="#article-155646.r9" rid="article-155646.r9">[9]</a>  Further, an observational study of 1000 patients readmitted within 30 days of discharge revealed that around 27 percent of these readmissions were considered potentially preventable, defined as those with more than a 50% chance that readmission could have been prevented.<a class="bibr" href="#article-155646.r10" rid="article-155646.r10">[10]</a>  The most common preventable factors were emergency department decision-making regarding readmission, failure to relay important information to outpatient providers, discharge of patients too soon, and lack of goals of care discussions among patients with serious illnesses. Additionally, a study using Medicare data for over 200,000 patients showed that initial admission rates played a more significant role in the regional variation of readmission rates than other factors such as case mix, hospital size, discharge planning, or the number of specialist physicians or primary care.<a class="bibr" href="#article-155646.r11" rid="article-155646.r11">[11]</a> Several common factors increase the likelihood of readmission that may be modifiable, especially those related to clinician or system-level issues. Such factors include:</p><p>
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<b>During Hospital: </b>
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</p><ul><li class="half_rhythm"><div><b>Inadequate handoffs</b>: Poor information transfer from providers to providers, particularly hospital-based to primary care providers. A meta-analysis found that only 12% and 34% of discharge summaries were received by aftercare providers at the time of the first appointment following hospitalization.<a class="bibr" href="#article-155646.r12" rid="article-155646.r12">[12]</a> Furthermore, the documentation often had errors, such as medication adjustment, pending tests, follow-up plans, referrals, etc., that can contribute to readmissions. </div></li></ul><ul><li class="half_rhythm"><div><b>Medication-related issues</b>:<b> </b>Newly prescribed medications or altered dosages during or after hospital discharge can react or cause adverse drug events that can prompt readmissions. Polypharmacy is another risk factor that contributes to readmissions.<a class="bibr" href="#article-155646.r13" rid="article-155646.r13">[13]</a> </div></li></ul><ul><li class="half_rhythm"><div><b>Higher-risk patients</b>: Certain readmission risk factors vary and can be clinical (such as high-risk medication use, multiple chronic conditions, specific diseases) or demographic/logistical (like prior hospitalization, race, low health literacy, limited social network, lower socioeconomic status, and discharge against medical advice).<a class="bibr" href="#article-155646.r14" rid="article-155646.r14">[14]</a><a class="bibr" href="#article-155646.r15" rid="article-155646.r15">[15]</a></div></li></ul><ul><li class="half_rhythm"><div><b>Complications in the hospital</b>: Some patients may develop nosocomial infections, pressure ulcers, falls, and procedure complications during or shortly after a hospital stay. These events can increase the rates of readmissions.</div></li></ul><p>
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<b>On Discharge</b>: </p><ul><li class="half_rhythm"><div><b>Therapeutic errors</b>:<b> </b>Medication reconciliation errors can lead to duplicating medications or improper dosages or frequency of medications, prompting early readmission. One study estimated that about 20% of patients experience adverse events after discharge, with medication-related issues being the most common.<a class="bibr" href="#article-155646.r16" rid="article-155646.r16">[16]</a> Roughly two-thirds of these adverse events were found to be either preventable or could have been mitigated. </div></li></ul><ul><li class="half_rhythm"><div><b>Premature discharge</b>:<b> </b>Discharging a patient prematurely for various reasons, like cost-effectiveness or prevention of hospital-acquired infections, can predispose the patient to another hospital visit sooner than expected.</div></li></ul><p>
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<b>After Discharge: </b>
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</p><ul><li class="half_rhythm"><div><b>Insufficient, delayed, or absent follow-up</b>:<b> </b>Only half of the Medicare beneficiaries who needed to be readmitted within 30 days of discharge had a follow-up visit with a clinician.<a class="bibr" href="#article-155646.r3" rid="article-155646.r3">[3]</a></div></li></ul><ul><li class="half_rhythm"><div><b>Inadequate post-discharge care</b>: Patients may not receive appropriate follow-up care, such as medication management, physical therapy, or home healthcare. This can worsen their condition and necessitate a return to the hospital.</div></li></ul><ul><li class="half_rhythm"><div><b>Medication mismanagement</b>: Patients may misunderstand or forget medication instructions, leading to incorrect dosages or missed doses. This can result in symptom exacerbation or complications, prompting readmission.</div></li></ul><ul><li class="half_rhythm"><div><b>Inadequate communication and coordination</b>: Poor communication between healthcare providers, insufficient care coordination, and the lack of a clear transition plan from hospital to home can result in readmission. Also, a language barrier amongst healthcare providers, staff, and patients can lead to further misinformation, as some things are just "lost in translation."</div></li></ul><ul><li class="half_rhythm"><div><b>Lack of patient education</b>: Many readmissions occur because patients do not fully understand their conditions or how to manage them. Inadequate patient education can lead to non-compliance with treatment plans and follow-up care.</div></li></ul><ul><li class="half_rhythm"><div><b>Social determinants of health</b>: Patients' social and economic circumstances can impact their ability to adhere to treatment recommendations. Factors such as transportation issues, food insecurity, and housing instability can increase the risk of readmission.</div></li></ul><p>
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<b>Strategies for Reducing Hospital Readmissions</b>
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</p><p>Healthcare institutions have been implementing various strategies to reduce hospital readmissions, with a focus on re-engineering the discharge process by improving patient care and education, enhancing communication and coordination, and addressing social determinants of health and arrangements for prompt follow-up.<a class="bibr" href="#article-155646.r17" rid="article-155646.r17">[17]</a> Here are some key strategies:</p><ul><li class="half_rhythm"><div><b>Care transition programs</b>: Hospitals can implement transition programs that help patients smoothly transition from inpatient to outpatient care. These programs often involve providing patients with a written care plan, coordinating follow-up appointments, and educating them about their condition and self-care.<a class="bibr" href="#article-155646.r18" rid="article-155646.r18">[18]</a> An excellent example of this is a study that evaluated the Care Transitions Intervention (CTI) program in which older patients were paired with a discharge nurse transition coach.<a class="bibr" href="#article-155646.r18" rid="article-155646.r18">[18]</a> The nurse (transition coach) helped the patient, family member, or caregiver and encouraged timely follow-ups, self-care, and patient education and awareness about what to do if a problem arises. The transition coach saw the patient before discharge, then at home 2 to 3 days post-discharge, followed by at least three telephone calls up to the first 28 days after discharge. As a result of this program, a significant reduction in 30- and 90-day readmission rates (8.3 versus 11.9 percent and 16.7 versus 22.5 percent, respectively) led to a cost-save of $500 per case.</div></li></ul><ul><li class="half_rhythm"><div><b>Medication reconciliation</b>: Hospitals should conduct medication reconciliation before patients are discharged to ensure that patients are aware of their medications, understand their dosages, and can manage their medications effectively. This can be crucial in preventing medication-related readmissions.<a class="bibr" href="#article-155646.r19" rid="article-155646.r19">[19]</a><a class="bibr" href="#article-155646.r20" rid="article-155646.r20">[20]</a><a class="bibr" href="#article-155646.r19" rid="article-155646.r19">[19]</a></div></li></ul><ul><li class="half_rhythm"><div><b>Post-discharge follow-up</b>: Healthcare institutions can schedule post-discharge follow-up appointments to monitor patients' progress and address any emerging issues. Telehealth services and home healthcare can also be utilized to provide remote care and support.<a class="bibr" href="#article-155646.r21" rid="article-155646.r21">[21]</a><a class="bibr" href="#article-155646.r22" rid="article-155646.r22">[22]</a></div></li></ul><ul><li class="half_rhythm"><div><b>Patient education</b>: Comprehensive patient education is important to ensure patients understand their conditions, treatment plans, and the importance of adhering to recommendations. Transparent, accessible educational materials and resources should be provided to patients and their families.</div></li></ul><ul><li class="half_rhythm"><div><b>Care coordination</b>: Improved communication and coordination between healthcare providers can help ensure patients receive continuous and comprehensive care. Electronic health records and secure communication systems can facilitate information sharing among healthcare teams.</div></li></ul><ul><li class="half_rhythm"><div><b>Addressing social determinants of health</b>: Hospitals can work with community organizations and social workers to assess and address patients' social determinants of health. Connecting patients with resources to address transportation, housing, and food security can help prevent readmissions.</div></li></ul><ul><li class="half_rhythm"><div><b>Quality improvement initiatives</b>: Healthcare institutions can implement continuous quality improvement programs to identify and address specific areas of concern related to readmissions. By analyzing data, hospitals can tailor their approaches to reduce readmissions for specific conditions or patient populations.<a class="bibr" href="#article-155646.r23" rid="article-155646.r23">[23]</a> A randomized controlled trial at a large academic hospital assessed 749 patients and explored the efficacy of a multidisciplinary team in minimizing readmissions and emergency department visits.<a class="bibr" href="#article-155646.r24" rid="article-155646.r24">[24]</a> The team comprised a nurse for discharge planning, a pharmacist responsible for post-discharge follow-up calls, pre-scheduled follow-up appointments, medication reconciliation, and a discharge instruction booklet tailored for low literacy. The rate of post-discharge hospital utilization was 31 percent for the intervention group compared with 44 percent for the control group. Patients in the intervention group were also more likely to follow up with their primary care provider.<a class="bibr" href="#article-155646.r25" rid="article-155646.r25">[25]</a></div></li></ul><ul><li class="half_rhythm"><div><b>Engaging patients and families</b>: Actively involving patients and their families in the care planning can improve their understanding and motivation to follow recommended treatments and self-care measures. </div></li></ul><p>
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<b>Conclusion</b>
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</p><p>Reducing hospital readmissions is not only a healthcare imperative but also a financial necessity. By addressing the root causes of readmissions and implementing strategies that focus on patient education, care coordination, and addressing social determinants of health, healthcare institutions can make significant strides in reducing readmissions and improving patient outcomes. Achieving a sustainable reduction in readmissions requires a holistic and patient-centered approach considering the multifaceted factors contributing to this issue. Ultimately, the success of these efforts not only benefits individual patients but also leads to the overall cost-effectiveness and efficiency of the healthcare system.</p></div><div id="article-155646.s2"><h2 id="_article-155646_s2_">Review Questions</h2><ul><li class="half_rhythm"><div>
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<a href="https://www.statpearls.com/articlelibrary/commentarticle/155646/?utm_source=pubmed&utm_campaign=comments&utm_content=155646" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Comment on this article.</a>
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</div></li></ul></div><div id="article-155646.s3"><h2 id="_article-155646_s3_">References</h2><dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>1.</dt><dd><div class="bk_ref" id="article-155646.r1">WOODSIDE M. A follow-up of psychiatric patients; one year's survey of patients discharged from the York Clinic. <span><span class="ref-journal">Guys Hosp Rep. </span>1953;<span class="ref-vol">102</span>(1):70-5.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/13034097" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 13034097</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>2.</dt><dd><div class="bk_ref" id="article-155646.r2">WOODSIDE M. York clinic: a note on readmissions. <span><span class="ref-journal">Guys Hosp Gaz. </span>1953 Feb 07;<span class="ref-vol">67</span>(1684):48-50.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/13021594" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 13021594</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>3.</dt><dd><div class="bk_ref" id="article-155646.r3">Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. <span><span class="ref-journal">N Engl J Med. </span>2009 Apr 02;<span class="ref-vol">360</span>(14):1418-28.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19339721" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19339721</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>4.</dt><dd><div class="bk_ref" id="article-155646.r4">Pandey A, Golwala H, Hall HM, Wang TY, Lu D, Xian Y, Chiswell K, Joynt KE, Goyal A, Das SR, Kumbhani D, Julien H, Fonarow GC, de Lemos JA. Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction: Findings From the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines. <span><span class="ref-journal">JAMA Cardiol. </span>2017 Jul 01;<span class="ref-vol">2</span>(7):723-731.</span> [<a href="/pmc/articles/PMC5815085/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5815085</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/28445559" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28445559</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>5.</dt><dd><div class="bk_ref" id="article-155646.r5">Kansagara D, Englander H, Salanitro A, Kagen D, Theobald C, Freeman M, Kripalani S. Risk prediction models for hospital readmission: a systematic review. <span><span class="ref-journal">JAMA. </span>2011 Oct 19;<span class="ref-vol">306</span>(15):1688-98.</span> [<a href="/pmc/articles/PMC3603349/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3603349</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22009101" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22009101</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>6.</dt><dd><div class="bk_ref" id="article-155646.r6">Sheingold SH, Zuckerman R, Shartzer A. Understanding Medicare Hospital Readmission Rates And Differing Penalties Between Safety-Net And Other Hospitals. <span><span class="ref-journal">Health Aff (Millwood). </span>2016 Jan;<span class="ref-vol">35</span>(1):124-31.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/26733710" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26733710</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>7.</dt><dd><div class="bk_ref" id="article-155646.r7">Abdul-Aziz AA, Hayward RA, Aaronson KD, Hummel SL. Association Between Medicare Hospital Readmission Penalties and 30-Day Combined Excess Readmission and Mortality. <span><span class="ref-journal">JAMA Cardiol. </span>2017 Feb 01;<span class="ref-vol">2</span>(2):200-203.</span> [<a href="/pmc/articles/PMC5503688/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5503688</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27784054" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27784054</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>8.</dt><dd><div class="bk_ref" id="article-155646.r8">Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, Observation, and the Hospital Readmissions Reduction Program. <span><span class="ref-journal">N Engl J Med. </span>2016 Apr 21;<span class="ref-vol">374</span>(16):1543-51.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/26910198" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26910198</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>9.</dt><dd><div class="bk_ref" id="article-155646.r9">van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. <span><span class="ref-journal">CMAJ. </span>2011 Apr 19;<span class="ref-vol">183</span>(7):E391-402.</span> [<a href="/pmc/articles/PMC3080556/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3080556</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/21444623" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21444623</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>10.</dt><dd><div class="bk_ref" id="article-155646.r10">Auerbach AD, Kripalani S, Vasilevskis EE, Sehgal N, Lindenauer PK, Metlay JP, Fletcher G, Ruhnke GW, Flanders SA, Kim C, Williams MV, Thomas L, Giang V, Herzig SJ, Patel K, Boscardin WJ, Robinson EJ, Schnipper JL. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. <span><span class="ref-journal">JAMA Intern Med. </span>2016 Apr;<span class="ref-vol">176</span>(4):484-93.</span> [<a href="/pmc/articles/PMC6900926/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6900926</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26954564" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26954564</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>11.</dt><dd><div class="bk_ref" id="article-155646.r11">Epstein AM, Jha AK, Orav EJ. The relationship between hospital admission rates and rehospitalizations. <span><span class="ref-journal">N Engl J Med. </span>2011 Dec 15;<span class="ref-vol">365</span>(24):2287-95.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/22168643" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22168643</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>12.</dt><dd><div class="bk_ref" id="article-155646.r12">Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. <span><span class="ref-journal">JAMA. </span>2007 Feb 28;<span class="ref-vol">297</span>(8):831-41.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/17327525" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17327525</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>13.</dt><dd><div class="bk_ref" id="article-155646.r13">Campbell SE, Seymour DG, Primrose WR., ACMEPLUS Project. A systematic literature review of factors affecting outcome in older medical patients admitted to hospital. <span><span class="ref-journal">Age Ageing. </span>2004 Mar;<span class="ref-vol">33</span>(2):110-5.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14960424" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 14960424</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>14.</dt><dd><div class="bk_ref" id="article-155646.r14">Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining readmission risk factors for general medicine patients. <span><span class="ref-journal">J Hosp Med. </span>2011 Feb;<span class="ref-vol">6</span>(2):54-60.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/20945293" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20945293</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>15.</dt><dd><div class="bk_ref" id="article-155646.r15">Foraker RE, Rose KM, Suchindran CM, Chang PP, McNeill AM, Rosamond WD. Socioeconomic status, Medicaid coverage, clinical comorbidity, and rehospitalization or death after an incident heart failure hospitalization: Atherosclerosis Risk in Communities cohort (1987 to 2004). <span><span class="ref-journal">Circ Heart Fail. </span>2011 May;<span class="ref-vol">4</span>(3):308-16.</span> [<a href="/pmc/articles/PMC3098576/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3098576</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/21430286" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21430286</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>16.</dt><dd><div class="bk_ref" id="article-155646.r16">Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, Khan A, van Walraven C. Adverse events among medical patients after discharge from hospital. <span><span class="ref-journal">CMAJ. </span>2004 Feb 03;<span class="ref-vol">170</span>(3):345-9.</span> [<a href="/pmc/articles/PMC331384/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC331384</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/14757670" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 14757670</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>17.</dt><dd><div class="bk_ref" id="article-155646.r17">Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. <span><span class="ref-journal">Ann Intern Med. </span>2011 Oct 18;<span class="ref-vol">155</span>(8):520-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/22007045" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22007045</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>18.</dt><dd><div class="bk_ref" id="article-155646.r18">Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. <span><span class="ref-journal">Arch Intern Med. </span>2006 Sep 25;<span class="ref-vol">166</span>(17):1822-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/17000937" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17000937</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>19.</dt><dd><div class="bk_ref" id="article-155646.r19">Phatak A, Prusi R, Ward B, Hansen LO, Williams MV, Vetter E, Chapman N, Postelnick M. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). <span><span class="ref-journal">J Hosp Med. </span>2016 Jan;<span class="ref-vol">11</span>(1):39-44.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/26434752" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26434752</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>20.</dt><dd><div class="bk_ref" id="article-155646.r20">Ohlsen JT, Søfteland E, Akselsen PE, Assmus J, Harthug S, Lein RK, Sevdalis N, Wæhle HV, Øvretveit J, Hartveit M. Rapid response systems, antibiotic stewardship and medication reconciliation: a scoping review on implementation factors, activities and outcomes. <span><span class="ref-journal">BMJ Qual Saf. </span>2024 Jun 06;</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/38844348" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 38844348</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>21.</dt><dd><div class="bk_ref" id="article-155646.r21">Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. <span><span class="ref-journal">Am J Med. </span>2001 Dec 21;<span class="ref-vol">111</span>(9B):26S-30S.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11790365" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 11790365</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>22.</dt><dd><div class="bk_ref" id="article-155646.r22">Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. <span><span class="ref-journal">J Gen Intern Med. </span>2008 Aug;<span class="ref-vol">23</span>(8):1228-33.</span> [<a href="/pmc/articles/PMC2517968/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2517968</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/18452048" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18452048</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>23.</dt><dd><div class="bk_ref" id="article-155646.r23">Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. <span><span class="ref-journal">Arch Intern Med. </span>1998 May 25;<span class="ref-vol">158</span>(10):1067-72.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/9605777" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9605777</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>24.</dt><dd><div class="bk_ref" id="article-155646.r24">Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, Forsythe SR, O'Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. <span><span class="ref-journal">Ann Intern Med. </span>2009 Feb 03;<span class="ref-vol">150</span>(3):178-87.</span> [<a href="/pmc/articles/PMC2738592/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2738592</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/19189907" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19189907</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>25.</dt><dd><div class="bk_ref" id="article-155646.r25">Patel SV, Arcidiacono A, Austin CP, Imburgio S, Heaton J, DiSandro K, Mathur D, Besa R, Angelo E, Walch B, Bakr M, Buccellato V, Frank E, Hossain MA, Asif A. Improving Patient Outcomes Using Measures to Increase Discharge Rates to Home. <span><span class="ref-journal">Cureus. </span>2024 May;<span class="ref-vol">16</span>(5):e59738.</span> [<a href="/pmc/articles/PMC11151191/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC11151191</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/38841032" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 38841032</span></a>]</div></dd></dl></dl></div><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Jasninder Dhaliwal declares no relevant financial relationships with ineligible companies.</p></div></dd></dl><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Ashujot Kaur Dang declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></dl></div></div></div><div class="fm-sec"><h2 id="_NBK606114_pubdet_">Publication Details</h2><h3>Author Information and Affiliations</h3><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Jasninder S. Dhaliwal</span><sup>1</sup>; <span itemprop="author">Ashujot Kaur Dang</span><sup>2</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> University of California Riverside</div><div class="affiliation"><sup>2</sup> University of California, Riverside</div><h3>Publication History</h3><p class="small">Last Update: <span itemprop="dateModified">June 7, 2024</span>.</p><h3>Copyright</h3><div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © 2025, StatPearls Publishing LLC.<p class="small">
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This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
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(<a href="https://creativecommons.org/licenses/by-nc-nd/4.0/" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=uri">
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http://creativecommons.org/licenses/by-nc-nd/4.0/
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</a>), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.
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</p></div></div><h3>Publisher</h3><p><a href="https://www.statpearls.com/" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">StatPearls Publishing</a>, Treasure Island (FL)</p><h3>NLM Citation</h3><p>Dhaliwal JS, Dang AK. Reducing Hospital Readmissions. [Updated 2024 Jun 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. <span class="bk_cite_avail"></span></p></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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