Reducing hospital readmission rates has proven to be a daunting challenge, especially among older patients. Indeed, nearly one-fifth of Medicare patients discharged from inpatient care are rehospitalized within 30 days, costing Medicare more than $17 billion annually, one study found. Health care providers can work toward lowering rehospitalization rates by improving transitions of care and performing medication reconciliation.

To date, no single intervention has proven to be effective for lowering rehospitalization rates, but most strategies involve an outpatient team composed of a physician, pharmacy staff, and nurses. For example, leveraging its hospitals, medical groups, and pharmacy technicians, HonorHealth, based in Phoenix, AZ, has lowered its readmission rate by 15% since 2015, according to Pamela Foster, MBA, vice president of care coordination. The pharmacy technicians, who assess patients and reach out to pharmacies, insurers, and PCPs, play a crucial role, she says.

Some organizations support the adoption of patient-centered medical homes (PCMHs) to reduce rehospitalizations. A 2019 study found significantly lowered readmission rates among geriatric patients who participated in all three components (i.e., nurse, pharmacist, and physician appointments) of a PCMH.

Foster notes that billing codes are available for coordinating transitions of care: for both physician and nonphysician staff, for patient interactions that are not conducted face to face (e.g., via telephone), and for researching third-party services such as educational resources.

Some shared EHR systems automatically inform outpatient or family physicians when one of their patients is hospitalized. These trigger mechanisms should be used whenever possible, she adds.

Medication reconciliation is also paramount, says Caroline Carney, MD, chief medical officer at Magellan Rx Management. Indeed, one study found that more than one-half of adverse events that occurred in the first three weeks after discharge were avoidable drug-related problems. “Often patients leave the hospital with one medication, and they have that same medication at home, perhaps in a different dosage, and are confused as to which one to take. This can lead to over-treatment.” Foster cautions that patients at high risk for this issue include those taking anticoagulants or diabetes drugs.

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