Background: Traditional readmission case review processes at our tertiary-care academic institution failed to identify obvious target processes for readmission reduction.  Looking for a more nuanced method of readmission review, we turned to our patients.   We conducted over 300 readmitted patient interviews and a focus group to learn from our patient’s experiences.   We then developed a comprehensive patient-centered readmission reduction program targeting the root causes of readmissions as determined by our patients. 

Purpose: To develop a patient-centered readmission reduction program targeting the root cause of readmissions as described by medicine patients in a tertiary care academic medical institution.

Description: 98 initial “pilot” in-person interviews of readmitted patients were conducted; a subgroup of the readmission cases were also reviewed by the discharging providers. Key findings included that patients associated preventable readmissions with a general sense of not feeling ready for discharge, and that patients and providers tended to disagree on readmission preventability.   Based on this initial data, 230 additional interviews were completed.  28% of patients reported not feeling ready for discharge.  Patients who did not feel ready for discharge were more likely to report a lack of symptom resolution (53% v. 17%, p<0.001).  Most patients reported having help in the home (80%), however  the subgroup who did not feel ready for discharge described  concerns about taking care of themselves at home (54% v. 25%; p<0.001).  Patients reported qualitatively that discharge paperwork was too long and not specific enough to their condition.  When asked outpatient resource use, 85% of patients reported having a primary care doctor whom they would feel comfortable calling, yet only 56% did so prior to coming back to the hospital.  Furthermore, rating on a numerical scale, patients reported greater relief than burden of being back in the hospital (7.7 SD 2.8 v. 5.9 SD 3.4;p<0.001).  

We have developed a comprehensive patient-centered readmission reduction program targeting key findings from these interview data, including: patient readiness, symptom control, discharge paperwork, and understanding why patients may not utilize available outpatient resources. To target patient readiness, we are piloting an “enhanced transition initiative” that includes an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they may face after they are discharged.  To improve pain and symptom control we have formed a multidisciplinary task force to optimize our Health System’s approach to pain control.  To address concerns over discharge instructions, we conducted a patient focus group to identify potential discharge paperwork enhancements.  Lastly, to better understand why patients may choose to seek emergency or hospital care rather than use outpatient resources such as their primary physician, we are assessing patients for decisional conflict—a measure of uncertainty when faced with multiple options—with regard to the choices they have in accessing outpatient resources.  

Conclusions: Through interviews of readmitted patients we identified novel causes for readmissions that were not previously identified through traditional readmission review processes at our institution.  Based on our findings we built a comprehensive patient-centered readmission reduction program.