Preventing avoidable rehospitalizations by understanding the characteristics of "frequent fliers".

This project used chart review to evaluate 22 patients labeled as "frequent fliers," each with 4 to 8 readmissions over a 6-month period at a Michigan community hospital. The goal was to identify whether the 4 key elements identified by the Institute for Healthcare Improvement for reducing rehospitalization had been put into place for these patients. It found that a clear discharge plan was only documented for 15 (68%) of the 22 patients. Better coordinated care is warranted.