Frequent readmissions pose a challenge to hospitals across the country. They are associated with increasing healthcare costs and display a failure to effectively care for certain groups of patients. The Centers for Medicare and Medicaid Services (CMS) apply a penalty towards hospitals with higher than expected 30-days readmission rates. In response, hospitals have implemented policies to identify and target potentially preventable readmissions. Instead of focusing on a single intervention, we propose a multi-disciplinary approach with multi-level interventions to identify factors for readmissions.


Frequently readmitted patients were defined as those with three or more admissions over the prior six months. A multidisciplinary team made up of hospitalists, residents, nurses, case managers and pharmacists met and agreed upon components of an enhanced transition care checklist which targeted common factors for readmissions. These factors included recognition of advance illnesses prompting palliative care evaluation, a post discharge follow up with an outpatient provider, determination of need for home services, medicine reconciliation, a written discharge plan, and a post 48 hours discharge phone call. This checklist was completed prior to discharge and patients were followed in the EMR for 90 days to see if they were readmitted. If readmitted, a chart audit was performed that included basic demographics, insurance, LACE score (a tool used to calculate readmission risk based on length of stay (LOS), acuity of admission, comorbidities and number of emergency room visits), time of discharge, LOS, discharge and readmission diagnosis, PCP information and other factors.  All information was entered into a database and analysis was performed by a biostatistician.


A total of 43 subjects were included in the study across two tertiary hospitals. Of those, 67.4% were readmitted within 90 days of their index discharge. Among readmitted patients, 72.4% of the subjects had an unavoidable readmission and 27.6% had an avoidable readmission. Of note, 48.3% of the subjects were readmitted for the same reason as their index discharge diagnosis. There were no significant associations between readmission and gender (p = 0.1807), hospital location (p = 0.6059), PMD access (p = 0.0804), Medicaid (p = 1.0000), Medicare (p = 0.1548), commercial insurance (p = 0.8798), index LACE (p = 0.6080) or index LOS (p = 0.8758).


Our study suggests that the majority of frequently admitted patients were readmitted for unavoidable reasons. Unavoidable factors are largely related to complex nature of chronic diseases, decreased functional status, health literacy and lack of support at home. Although this is a small scale study, it further demonstrates that the complexities associated with multiple chronic comorbid conditions, despite multi-level interventions, continue to make reducing readmissions a challenge.