National Academy of Medicine

Treating a Chronic Condition: Efforts to Reduce Avoidable Readmissions at U.S. Hospitals

By Risa Lavizzo-Mourey
August 13, 2013 | Commentary

In 2013, the Centers for Medicare & Medicaid Services (CMS) reported that the 30-day, all-cause readmission rate had decreased to 17.8 percent, after averaging 19 percent for the past 5 years. This improvement translates to 70,000 fewer readmissions in 2012, but, more importantly, it means that real people behind these numbers didn’t have to return to the hospital unnecessarily. [1]

This, of course, is good news and demonstrable evidence that CMS’s Hospital Readmissions Reduction Program is moving the needle in the right direction. The program currently reduces Medicare reimbursements for hospitals with high rates of heart attack, heart failure, and pneumonia readmissions. For fiscal year 2014, CMS recommends a revised methodology to take into account planned readmissions for the existing three measures and, for fiscal year 2015, proposes two new measures: readmissions for hip/knee arthroplasty and chronic obstructive pulmonary disease. [2]

As a gerontologist, I’ve long recognized that some hospital readmissions are a planned element of treatment. Others are unscheduled but difficult to prevent; patients go home, unexpected problems arise, and a trip back to the hospital is required. But many of these readmissions can and should be prevented. They are the result of a fragmented system of care that too often leaves discharged patients without the resources they need.

Some patients are discharged prematurely; others do not understand how to fully care for themselves outside the hospital environment. Often, primary care providers do not know that their patient has been in the hospital, much less discharged. And other patients lack access to the care services or medications they need to fully heal. Because of the Medicare Readmissions Reduction Program, our nation’s hospitals are fully engaged in efforts to reduce avoidable returns. Physicians, nurses, and others inside hospitals are working to do a better job of educating patients and their caregivers about what to do when they go home. They are also working harder to connect them with primary care and other social support services.

The Robert Wood Johnson Foundation’s (RWJF’s) Care About Your Care initiative highlights work around the country to improve care transitions. Through this effort, RWJF recently invited frontline health care providers to submit videos explaining how they are improving transitions. We expected to receive a handful of entries. Instead, we received more than 100 videos showcasing innovative, patient-centered approaches. [3]

One that stood out featured the “Good to Go” program at Cullman Regional Medical Center in Cullman, Alabama, which helps patients understand and comply with their discharge instructions by having caregivers record discharge sessions. The patient and family can listen to the captured conversation, and caregivers can access instructional videos, baseline photos, appointment reminders, and medication lists from any phone or computer using secure login information.

Creating financial incentives for hospitals to address high readmission rates is important, but, on its own, it is an insufficient solution to a complex problem. Policy must also confront the broader issues brought to light in The Revolving Door: A Report on U.S. Hospital Readmissions, a report commissioned by RWJF that includes an analysis of Medicare data by the Dartmouth Atlas Project. The overarching finding is that where you find high rates of admissions, you also find high rates of readmissions, because some communities use hospitals as a venue of care more than others, regardless of illness levels within the community. [4]

This is vital to understand, because hospitals are a costly alternative to community-based care. To get people the care they need outside the hospital, policy and payment initiatives should account for the interplay between the distribution of hospital resources and the role of delivery and reimbursement systems. We must see the problem in this larger context if we want to make more than marginal improvement.



  1. CMS (Centers for Medicare & Medicaid Services). 2013. CMS Issues Proposed Inpatient Payment Regulation (accessed May 2013).
  2. CMS. 2013. Lower Costs, Better Care: Reforming Our Health Care Delivery System (accessed May 2013).
  3. RWJF (Robert Wood Johnson Foundation). 2013. Transitions to Better Care Video Contest (accessed May 2013).
  4. RWJF. 2013. The Revolving Door: A Report on U.S. Hospital Readmissions (accessed May 2013).



Note: Authored commentaries in this IOM Series draw on the experience and expertise of field leaders to highlight health and health care innovations they feel have the potential, if engaged at scale, to foster transformative progress toward the continuously learning health system envisioned by the IOM. Statements are personal, and are not those of the IOM or the National Academies.

In this commentary, Risa Lavizzo-Mourey, President and CEO of the Robert Wood Johnson Foundation, describes the complex array of determinants inherent to hospital readmissions and offers suggestions on the best ways to confront them. Her discussion touches on several concepts central to continuously learning health care, including the opportunities for:

  • Expanded investigation into factors contributing to readmissions, including premature discharge, insufficient patient-clinician communication, and lack of resources;
  • Strong partnerships between hospital-based clinicians and those responsible for primary care and social services to ensure coordinated transitions from hospital settings back to communities;
  • Provision of support tools at the time of discharge to ensure full understanding of and compliance with discharge instructions; and
  • Greater focus on the interplay between the distribution of hospital resources and the role of delivery and reimbursement systems when designing initiatives to overcome persistently high readmission rates.

Information on the IOM’s Learning Health System work may be found at



Suggested Citation

Lavizzo-Mourey, R. 2013. Treating a Chronic Condition: Efforts to Reduce Avoidable Readmissions at U. S. Hospitals. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. doi: 10.31478/201308c


The views expressed in this commentary are those of the author and not necessarily of the author’s organization or of the Institute of Medicine. The commentary is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.


Disclaimer: The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.