Hospital readmissions under the spotlight.

Healthcare leaders see the future of their dynamic industry through the eyes of patients, families, providers, clinicians, employers, health insurers, and policymakers. As healthcare organizations face growing economic challenges and the nation engages in comprehensive healthcare reform, reducing preventable readmissions is considered part of the solution to achieving new system-wide efficiencies. Healthcare leaders can adopt a fresh approach to reducing preventable readmissions that includes three basic components: (1) identify patients at risk for readmission based on sociodemographic factors, care-related factors, and measures of severity of illness; (2) anticipate reform that aligns reimbursements and payment incentives for readmission reductions; and (3) structure coordinated, patient-centered discharge planning. Three innovative programs can be used to coordinate care at discharge: the Society of Hospital Medicine's Better Outcomes for Older Adults Through Safe Transitions project; Boston University Medical Center's Reengineered Hospital Discharge project; and the Institute for Healthcare Improvement's STate Action on Avoidable Rehospitalizations initiative. This three-pronged approach will help organizations proactively create mechanisms that are aligned with the national agenda and that keep people healthy at home after hospital discharge.