Forum Session

Preventing Hospital Readmissions: How Can Care Transitions for Medicare Beneficiaries Be Improved?
October 28, 2011


Carol V. O'Shaughnessy, MA


The Patient Protection and Affordable Care Act (PPACA) of 2010 included a provision to reduce Medicare payments to hospitals that have "excessive readmissions." This provision is meant to spur hospitals to examine their discharge planning procedures and ensure that they have adequately prepared patients for transition to post-hospital care. Inadequate discharge planning and follow-up care for patients after a hospitalization often contribute to high readmission rates, higher costs, and potentially poorer health outcomes. Successful post-hospital care can be facilitated by many factors, especially coordination by hospitals with family caregivers, the patient’s primary care physician, nursing homes, and home care agencies. However, many issues may contribute to poor transitions, including lack of family and social supports at home; lack of (or limited access to) a “usual” source of care; and poor communication between the hospital, the patient’s physician, family caregivers, and other post-acute providers. This Forum session examined the extent and causes of preventable readmissions and explored some examples of initiatives hospitals and community service providers are undertaking to ensure successful transitions to post-hospital care.


Stephen F. Jencks, MD, MPH
Consultant in Healthcare Safety and Quality

Carol Levine, MA
Director, Families and Health Care Project
United Hospital Fund (New York City)

Steven R. Counsell, MD
Mary Elizabeth Mitchell Professor
Director, Geriatrics
Indiana University
Scientist, Center for Aging Research
Indiana University School of Medicine

Victoria Vaughn, RN
Director, Community Health Services
St. Mary’s Good Samaritan Hospital Centralia, Illinois

Slides from the presentations by Dr. Jencks, Ms. Levine, Dr. Counsell, and Ms. Vaughn are available for download.

Related Materials

Stephen F. Jencks, Mark V. Williams, and Eric A. Coleman, "Rehospitalizations among Patients in the Medicare Fee-For-Service Program," New England Journal of Medicine, 360, no. 14, (April 2, 2009): pp. 1418-1428.

Luke O. Hansen et al., "Interventions to Reduce 30-Day Rehospitalization: A Systematic Review," Annals of Internal Medicine, 155, no. 8 (October 18, 2011): pp. 520-528.

David C. Goodman et al., "After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries," The Dartmouth Institute, September 28, 2011.

Medicare Payment Advisory Commission (MedPAC), "Reforming America’s Health Care Delivery System," testimony of Glenn M. Hackbarth, Chairman of MedPAC, before the Senate Finance Committee Roundtable on Reforming America’s Health Care Delivery System, April 21, 2009.

Kathryn Linehan, "Discharge Planning and Medical Social Services in Fee-for-Service Medicare," (National Health Policy Forum, The Basics, October 14, 2009).

Norbert I. Goldfield et al., "Identifying Potentially Preventable Readmissions," Health Care Financing Review, 30, no. 1 (Fall 2008): pp. 75–91.

Christine Caffrey, "Potentially Preventable Emergency Department Visits by Nursing Home Residents: United States, 2004," NCHS Data Brief, no. 22, April 2010.

H. Joanna Jiang et al., "Potentially Preventable Hospitalizations among Medicare-Medicaid Dual Eligibles, 2008," Healthcare Cost and Utilization Project, Statistical Brief no. 96, September 2010.

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