Preventing Readmissions by Making Discharge Safer

Active follow-up methods for chronic heart failure patients led to reduced readmissions six months and one year postdischarge, according to a Cochrane Database of Systematic Reviews update, published online September 12, 2012, that reviewed 25 clinical trials with almost 6,000 patients. The update looked into the effects of three types of care post-hospitalization: (1) intensive monitoring through telephone calls and nurse visits to the home, (2) clinical interventions with a specialist at the chronic heart failure clinic, and (3) various interventions guided by a team of professionals. While the researchers could not identify the most effective component of the monitoring programs evaluated, they found that follow-up telephone calls from nurses were a common element associated with fewer readmissions. In another study about decreasing readmission rates, published in the August 2012American Journal of Managed Care, researchers found that a managed care organization that employed a point-of-care (POC) team made up of a variety of healthcare professionals (e.g., nurse, social worker, pharmacist, health navigator) at physician offices treating plan members significantly reduced 30-day readmission rates and the associated costs for patients who had been discharged from the hospital.