JAMA Commentary Offers Perspective on Access to Healthcare and Framework for Reducing Hospital Readmissions
Policies from the Centers for Medicare & Medicaid Services (CMS) will soon penalize hospitals when their patients are frequently readmitted within 30 days of discharge. As a result, clinicians, healthcare leaders, and policymakers are searching for ways to reduce readmissions. The current understanding of what drives readmissions focuses on the quality of the inpatient discharge process and on patients' health status. However, authors argue that readmission rate is neither a quality metric nor a measure of patients' health status. Rather, it is a measure of health service use that is influenced by quality and health status. Patient-level determinants of readmission include not only health status, but also access to socioeconomic resources such as stable housing, social support, and food. These factors affect the patient's ability to adhere to hospital discharge recommendations and, thus, influence readmission risk. This Commentary discusses how a patient's level of access to healthcare can influence readmission risk, and proposes a broader framework that can be used to identify alternative strategies to reduce readmissions - a framework in which readmission rates are determined by access, social determinants of health, and regulatory policies.
- High levels of access may lead to high readmission risk. A landmark VA study revealed that intensive post-discharge medical care increased rather than decreased readmission rates. This paradox may be secondary to "pent-up demand," whereby vulnerable patients lack access to socioeconomic resources that enable self-care and remain at high risk of relapse. Increased access to care facilitates closer monitoring of these relapses and higher rates of referral back to the hospital.
- Low levels of access may lead to high or low readmission risk. Patients who lack access to social support, child care or transportation may have trouble adhering to post-discharge instructions or may not get timely follow-up appointments, putting them at risk for readmission. At the same time, it is possible for hospitals to reduce readmission rates by decreasing access. As hospitals face readmission penalties, ED physicians may be under pressure to justify each readmission. This increases the likelihood that socioeconomically vulnerable patients will be discharged home in high-risk situations that depend on self-care and follow-up - resources they often lack.
- Based on the authors' proposed framework, reducing readmissions among vulnerable patients will require improving access to both outpatient health services and socioeconomic resources. Three strategies may help healthcare leaders achieve these goals:
- Consider social factors when determining patient readmission risk.
- Monitor consequences of readmission penalties, especially among socioeconomically vulnerable patients.
- Expand the hospital's scope beyond traditional health services, e.g., serve as a vehicle for connecting high-risk patients to socioeconomic resources such as addiction counseling and community centers.
Dr. Kangovi is an HSR&D investigator affiliated with the Philadelphia VAMC.
Kangovi S and Grande D. Hospital Readmissions – Not Just a Measure of Quality. JAMA, Commentary. October 26, 2011;306(16):1796-1797.