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Preventing Readmissions Through Comprehensive Discharge Planning

Hunter, Tabitha BSN, RN, IQCI; Nelson, James “Rex RN-BC, CCM, MBA; Birmingham, Jackie BSN, RN, MS, CMAC

doi: 10.1097/NCM.0b013e31827de1ce

Case managers, including nurses and social workers, provide essential services to hospitalized patients, including mandated discharge planning that has been shown to impact patient safety and patient outcomes. The heightened attention to readmission is evident in both reimbursement and accreditation initiatives. The Centers for Medicare & Medicaid Services, Office of Clinical Standards & Quality/Survey & Certification Group, is revising worksheets to be used by surveyors to review how hospitals are complying with the Medicare Conditions of Participation with a focus on discharge planning as it relates to patient safety. This is an opportunity for case managers to apply the principles of case management to the targeted problem of readmissions. Now case managers must identify the reasons for readmission on a patient-by-patient basis, collect data, analyze processes, and then change practice in the hospital and work more closely with community-based providers.

Purpose/Objectives: The purpose of this article is to recommend improvement in a consistent case management practice that will positively influence patient readmissions.

Primary Practice Setting: Hospital-based case managers who are responsible for discharge planning functions. Hospital administrators will also find this information valuable as a tool to assess strategies to control preventable readmissions and to comply with the Medicare Conditions of Participation for discharge planning.

Findings and Conclusions: Hospital-based case managers, responsible for discharge planning, have a unique opportunity to interact face-to-face with patients who are readmitted to determine factors that lead to the readmission. Case managers need to change their practice to include assessing patients on the basis of their prior level of care. Pharmacists need to play a bigger role in discharge planning, especially for patients who have experienced a potentially avoidable readmission. Working closely with community-based providers is essential to target reasons for readmission. The Medicare Conditions of Participation for Discharge Planning can be used not only to show compliance but as tools to evaluate current practice and identify areas of improvement.

Implications for Case Management PracticePreventable readmissions or rehospitalizations directly affect patient safety, patient outcome, hospital reimbursement, and hospital accreditation. Preventable readmissions can be controlled by comprehensive discharge planning. Case managers are directly involved in discharge planning and thus have direct accountability regarding readmissions; therefore, they must refine the admission assessment screening to include specific information based on a patient's preadmission level of care. Collaboration with community-based providers is essential to managing readmissions or rehospitalizations. Hospitals will find it beneficial to track readmissions by using specific data points unique to readmissions such as source of admission and previous length of stay. Self-assessment of compliance will help identify opportunities for quality improvement in the case management department.

Please Note: Rules and regulations are constantly changing. It is critical to monitor changes in standards. Information contained in this article is current at the time of submission, and readers are encouraged to review the content of this article with administration before implementing changes.

Supplemental Digital Content is Available in the Text.

Tabitha Hunter, BSN, RN, IQCI, is Regional Director for the Iasis Healthcare Corporation in Arizona. In this position, she is responsible for case management, quality assurance, and risk management along with regulatory compliance. Her long-standing interests include the impact of case management on patient safety and regulatory compliance.

James “Rex” Nelson, RN-BC, CCM, MBA, has years of experience in case management in health care delivery systems. He has a special interest in care coordination as it relates to patient safety during the transition of care from acute care hospitals.

Jackie Birmingham, BSN, MS, RN, CMAC, is a consultant to hospitals, post-acute providers and payers. Her primary interest is focused on discharge planning as a function within the case management and care coordination

Address correspondence to James “Rex” Nelson, RN-BC, CCM, MBA, 3942 East Kesler Lane, Gilbert, AZ 85295 (

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

The authors report no conflicts of interest.

Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.