According to data from the Centers for Medicare and Medicaid Services (CMS), nearly one in five Medicare patients in the US are readmitted to the hospital within 30 days of discharge. Unplanned readmissions not only signify potential gaps in care quality but also put an immense financial burden on the healthcare system. Understanding the reasons behind these readmissions can provide the key to developing effective strategies to mitigate this issue. Let’s examine the top three reasons for unplanned readmissions in US healthcare.

1. Chronic Disease Management

Chronic diseases such as heart disease, diabetes, COPD (chronic obstructive pulmonary disease), and kidney disease are among the leading causes of hospital readmissions. The complexity of managing these diseases often requires consistent medical attention, adherence to medication, and lifestyle modifications.

However, managing these diseases outside the hospital setting can be challenging due to various reasons like patient comprehension, social determinants, or even accessibility to consistent, quality healthcare. Hence, the failure to manage these conditions often leads to a worsening of symptoms and subsequent readmission.

2. Inadequate Post-Discharge Care

Post-discharge care plays a pivotal role in preventing hospital readmissions. Poor communication during the hand-off process, inadequate patient education about their condition, insufficient arrangement for post-acute care services, or a lack of social support can lead to serious post-discharge complications, driving readmissions.

A patient’s inability to follow through with prescribed medication regimens or misunderstanding their discharge instructions can have serious consequences on their health. Furthermore, some patients might require rehabilitation or specialized care post-discharge, and if these services are not arranged or not accessible, it can result in a rapid decline in their health status leading to readmission.

3. Socioeconomic Factors

Socioeconomic factors have a significant influence on hospital readmissions. These include income level, education, employment status, health insurance coverage, and more. Patients from lower socioeconomic backgrounds often face barriers to access appropriate healthcare services, lack a support system for disease management, and struggle with healthcare literacy.

For example, patients who can’t afford their medications, or who lack transportation to follow-up appointments, are more likely to experience health complications leading to readmissions. Moreover, patients who lack health literacy might not fully understand their medical conditions and the importance of medication adherence, which further increases the risk of readmission.

Reducing Readmissions

Healthcare systems should take a comprehensive and patient-centered approach to care delivery, focusing not only on in-hospital treatment but also on effective outpatient solutions. This includes chronic disease management, robust post-discharge care, and addressing socioeconomic determinants of health.

A proven means of reducing readmissions is by improving communications with patients. Drastically increasing the number of touchpoints assures that minor issues won’t turn into big problems, reduces appointment no-shows, and, importantly, provides patients with emotional support that they may lack at home.

Companies such as Twig Health offer outsourced care management services, with nurses that text with patients, 24/7, addressing problems, verifying adherence to care protocols, educating, and more.

Solutions such as Twig, and others, significantly reduce the number of unplanned readmissions, leading to improved patient outcomes and more efficient use of healthcare resources.