期刊
ANNUAL REVIEW OF MEDICINE, VOL 65
卷 65, 期 -, 页码 471-485出版社
ANNUAL REVIEWS
DOI: 10.1146/annurev-med-022613-090415
关键词
transitions of care; hospital discharge; readmission risk; postacute care
资金
- NHLBI NIH HHS [R01HL109388, R01 HL109388] Funding Source: Medline
- NIA NIH HHS [K23 AG040157, K23AG040157] Funding Source: Medline
- NATIONAL HEART, LUNG, AND BLOOD INSTITUTE [R01HL109388] Funding Source: NIH RePORTER
- NATIONAL INSTITUTE ON AGING [K23AG040157] Funding Source: NIH RePORTER
New financial penalties for institutions with high readmission rates have intensified efforts to reduce rehospitalization. Several interventions that involve multiple components (e.g., patient needs assessment, medication reconciliation, patient education, arranging timely outpatient appointments, and providing telephone follow-up) have successfully reduced readmission rates for patients discharged to home. The effect of interventions on readmission rates is related to the number of components implemented; single-component interventions are unlikely to reduce readmissions significantly. For patients discharged to postacute care facilities, multicomponent interventions have reduced readmissions through enhanced communication, medication safety, advanced care planning, and enhanced training to manage medical conditions that commonly precipitate readmission. To help hospitals direct resources and services to patients with greater likelihood of readmission, risk-stratification methods are available. Future work should better define the roles of home-based services, information technology, mental health care, caregiver support, community partnerships, and new transitional care personnel.
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