Monday Memo
Monday Memo
Monday, January 18, 2016
What's NEW at Athena Forum

Reduce Readmissions: Identify High-risk Patients

Nearly one in five Medicare patients is readmitted within 30 days of hospitalization. The nationwide cost of preventable readmissions under Medicare has been pegged at $17 billion, according to the Centers for Medicare and Medicaid Services (CMS).

Preventable readmissions remain a challenge for the healthcare system. Patient characteristics significantly affect readmission risk. Identifying high-risk patients involves recognizing that some patients have to contend with risk factors such as:

  • medical complexity
    • chronic health conditions
    • behavioral health issues
    • multiple medications
  • social complexity
    • lack transportation to get home from the hospital or to pick up prescription medications

[Managed Healthcare Executive, December 20, 2015, Four Ways to Reduce Re-Admissions]


Tips from our featured course

DC Planning: Risk Assessment Considerations

Patients with multiple diagnoses and/or risk factors present challenges to the discharge planning team that take extra time and energy to research and incorporate into the plan if it is going to be effective and meet the patient's unique needs.

The discharge planner is usually the best person to work with the patient (if feasible) and/or the family to establish preliminary goals for complex cases and then share these goals with the rest of the team.

[Improving Outcomes in Discharge Planning, Module B, Patient-Centered DC Planning]


Harm Risk Behaviors: BH Associated Readmissions

Mood disorders, schizophrenia, substance and alcohol use, and other psychotic disorders are among the top 10 reasons patients were readmitted to the hospital in 2011. The uninsured had $165 million in annual behavioral health-related readmission costs. These findings draw attention to our system's continuing need to better address behavioral health.

Integrating behavioral health care within primary care settings not only improves access to the patients who need these services but also reduces hospital readmission costs.

[Harm Risk Behaviors, Module F, CM Role]


Notice from the Publisher

I want to thank our 20,000 healthcare professionals for requesting new topics on Athena Forum.

Thomas A. Rasmussen
CEO & Publisher
Athena Forum Institute

Monday Memo Editor

Cathy Wright, BSN, RN

Clinical Editor

Athena Forum

Contact the Editor


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