The Robert Wood Johnson Foundation calls it “the revolving door syndrome.” In the U.S., one in five Medicare patients discharged from a hospital is readmitted in 30 days, largely because four out of every five patients have no direct communication with their doctors and primary care physicians after leaving the hospital.

At “Care About Your Care,” a panel discussion hosted Wednesday in Washington, D.C., public health and medical experts broke down the problem — avoidable hospital readmissions and poor care transitions — and what can be done to fix it.

“This issue is further on the radar screen of health care providers, and that’s good news,” said Risa Lavizzo-Mourey, president and CEO of the foundation. “We’re going to need to work together to stop that revolving door. … There is a lot of room for improvement.”

RWJF report on hospitals

In a report released Wednesday, the Robert Wood Johnson Foundation presented new data on U.S. hospital readmissions and ways patients and health workers can help reduce rates. Photo by RWJF

Lavizzo-Mourey introduced a report released yesterday detailing troubling new data on hospital readmissions. In 2010, one in eight Medicare patients was readmitted to the hospital within 30 days of being released after surgery, while the rate of return was one in six for patients in the hospital for non-surgeries.

However, numerous initiatives nationwide have been implemented to reduce readmissions, including:

  • Care Transitions Intervention: a four-week program, which has been adopted by 750 U.S. organizations, that pairs transition coaches with patients who have complex conditions;
  • Transitional Care Model: in which “transitional care nurses” provide  in-hospital planning and home follow-up for chronically ill, high-risk older adults hospitalized for common medical and surgical conditions; and
  • Project RED: a research group at Boston University Medical Center that develops and tests strategies to reduce hospital readmissions, relying on components such as language assistance, post-discharge outpatient services, telephone support and access to primary and follow-up care.

The foundation also offers an online toolkit, “How to avoid being readmitted to the hospital,” including a self-help plan for discharged patients.

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