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Doc, I am Back Again

Just recently, I admitted a patient into the hospital for a flare of congestive heart failure. As I reviewed his history with our new electronic medical record system, I was astonished to find that he had 10 re-hospitalizations in this past year with one just two weeks prior.

‘What happened?’ I ask him.

‘I don’t know. This always happens. When I feel the fluid starting to build up, I know I have to come in.’

When I probed further, he said that he did not have a chance to fill his prescriptions to treat his heart failure when he last left the hospital. But probing even further, he did not have a chance to apply for his Grady card, a pseudo-insurance device issued by Grady Memorial Hospital (GMH), which would have helped reduce the cost of his medications.

‘Why didn’t you get a Grady card?’ I asked.

Well, a few things were required for him to get a Grady card: he needed a form of identification (which he had), a source of income (which he did not have, although he was in the process of applying for disability), and a proof of residency (which he did not have as he was floating between different shelters).

 ‘I knew it wasn’t going to be easy, so I didn’t get it.’

He was right. It didn’t sound easy.

To put things into a little more perspective, one of five Medicare hospital patients return to the hospital within 30 days at a cost to Medicare of $12 billion to $15 billion a year.1 In 2004, the cost to Medicare of unplanned re-hospitalizations was $17.4 billion of the $102.6 billion in hospital payments (17%). And what more, a 2007 congressional report by the Medicare Payment Advisory Commission stated that 75% of readmissions can be avoided with better care!2

Granted my patient does not have Medicare, his poor socioeconomic status and medical illness already places him at a high risk for re-hospitalization rates. Hospital readmissions pose both a significant emotional and psychological (not to mention physical) burden upon our patients and a financial burden upon both our patients and our health care system. Therefore, reducing preventable readmissions is a pertinent part of the solution to reducing system-wide inefficiencies, improving quality of care, and decreasing costs associated with care.

Reasons for readmissions are multiple and include: poor health literacy, multiple co-morbidities, medication or medical errors, lack of primary care follow-up, and dysfunctional social environments.

Several interventions have been shown to effectively reduce the rate of preventable re-admissions such as appropriate hospital discharge planning, improved patient education, and close primary care follow-up, but we need to continue to implement these interventions nationwide, and more importantly, work with our governments, health care organizations, other health care professionals to address the socio-economic factors that preclude many of our patients from accessing health care, subsequently leading to them using the emergency room when their illness gets to a more serious stage.

Now under our new health care law, the Centers for Medicare and Medicaid Services will use a 30-day cutoff to start penalizing hospitals with higher than expected rates of re-admissions. Hopefully this will create the incentive to implement programs that will improve care coordination upon discharge and in follow-up and provide better quality of care for our patients.

Several innovative programs are already at the forefront in designing programs to improve care coordination at discharge: the Society of Hospital Medicine’s Better Outcomes for Older Adults Through Safe Transitions (BOOST) project; Boston University Medical Center’s Reengineered Hospital Discharge (RED) project; and the Institute for Healthcare Improvement’s State Action on Avoidable Rehospitalizations initiative.

We need to desperately join our colleagues in this effort!

Check out Heritage Health Prize awarding a prize worth $3 million dollars to a team that is able to develop a breakthrough algorithm to predict and prevent avoidable re-hospitalizations.

Perhaps this may be our chance to fight for our patient’s right for quality care and to take a stab at tackling our ailing health care system.


1Jencks SF, Williams MV, Coleman EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine. 2009; 360(14): 1418-1428.

2MEDPAC, Report to the Congress:  Promoting Greater Efficiency in Medicare, June 2007.

Share Your Comments


  1. Alice Chen

    My hospitalist group was just talking about this last night, trying to think of strategies to improve our readmission rates. Feels good to have an incentive to keep our patients healthy.

    Thanks for highlighting this important issue and the opportunities we have to make some strides here!

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