After a successful hospital stay, the most important task for patients, families and hospital staff is preparing for a successful discharge to their home. It is disappointing for everyone, and hugely expensive, if a patient requires an unexpected readmission into hospital. Factors contributing to readmission include premature discharge home, inadequate post-hospital support and complications stemming from a hospital stay such as pressure ulcers and hospital-acquired infections.

Research shows that readmissions for older Australians are most often caused by incorrect use or discontinued use of medication and not attending follow-up doctor's appointments. These risk factors increase in cases where the patient lacks a family support system at home.

Professor David Ben-Tovim, director of the Flinders Medical Centre's units for redesigning care and clinical epidemiology has said that readmission rates are "a legitimate concern" in Australia and deserve closer examination. Across Australia in all hospitals (public and Private) and all age groups 1% of patients are readmitted within 28-days. For public hospitals this rate has been as high as 2.75% while for private hospitals it is much lower at 0.53%.

Professor Debora Picone, chief executive officer of the Australian Commission on Safety and Quality in Health Care, agreed that more study on readmission rates in Australia was needed.

There is no question that readmission rates here are too high. There are very big variations across regions and particularly between states.

A Victorian state government-commissioned investigation has found more than 103,000 people returned to public hospitals within 30 days of being discharged costing the system about $431 million. In Victoria unplanned hospital readmissions utilise approximately 1,648 beds of the public hospital bed stock per annum and 456 of the private hospital bed stock per annum, indicating that a reduction in avoidable readmissions presents a significant efficiency opportunity for the health care system. Health Insurance companies are footing a large percentage of the readmission bill.

Across Australia the costs of avoidable hospital readmissions are close to $1.5billion.

Professor David Ben-Tovim, said it was "very good practice" to understand why patients came back, to find ways of minimising readmission and to reduce the burden on hospitals. He quoted international studies to try to discover the patient variables involved in readmission rates, and how hospitals could improve patient care.

What all the studies showed is that it is not uncommon for patients to be readmitted within 30 days of their initial discharge. That is clearly a matter of concern for everybody — a legitimate source of concern

In a 2013 study reported by the Royal Australasian College of Physicians 'unplanned readmissions effect up to 25% of acutely hospitalised older patients, and many may be potentially preventable'. Studies show that older adults with Congestive Heart Failure are likely to experience multiple readmissions to hospital.

The political focus on hospital care in Australia has traditionally been on waiting lists for elective surgery.

The sensation in the news has really been about the reduction of waiting lists while what is lost in the debate is the enormous cost to the health system of preventable unplanned readmissions. Financial and staffing pressure on hospitals, particularly government hospitals, results in patients being discharged as early as possible. This, in itself, is not a problem provided a scheme is in place to support the patient at home after discharge. The arithmetic is simple, poor post-discharge support = higher readmission rates = cost blow out.

While older Australians with advanced diseases and multi-morbidity will always have a higher propensity for readmission, the causal factors such as poor medication management and missing follow up appointments can be reduced significantly. A system of post-discharge patient health risk assessments and health coaching can reduce readmissions still further.

At Right at Home a system using personal care workers (we call them Care Navigators) has been shown to reduce hospital readmissions. Well trained carers in the community, given an understanding of the causes of hospital readmission and effective preventative measures, can have a huge impact. The carer supports the patient after discharge by making weekly visits to ensure that medication is being taken correctly, they report on 'red flags' that indicate whether the patient is recovering according to plan and they help the patient attend follow up appointments. They also provide health information, and with the support of nurse care managers, can set up and implement a long term health plan. The cost is a small fraction of the cost of hospital readmission.

In a recent program run by Right at Home using care navigators for Forsyth Hospital in Winston-Salem, North Carolina readmissions were reduced 60% and Emergency Room visits were reduced 43%. The costs savings in reduced readmissions is huge for the health system especially Health Insurance companies.

We're really excited to see these results because it proves that our model works. We believe that home care agencies using nurse managers are ideally suited to reduce hospital readmission and can drive a major transformation in Australian health care.

Daryl Sahli 

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