Hospital Readmissions Reduction Program

The Problem of Rehospitalizations

Rehospitalizations continue to occur far too often, when they could have been avoidable. The rates of readmission within 30 days vary by age, condition, hospital, and other factors. However, for many conditions, between 1 in 3 and 1 in 5 patients will be readmitted within 30 days of leaving the hospital. Despite various hospital readmissions reduction programs, we haven’t seen significant improvement in these rates. Even penalties waged on hospitals who failed to reduce their readmissions rates have not had the expected effect.

And, studies have continued to show that at least a third of rehospitalizations are avoidable.

Some of the main causes of rehospitalizations are:

  1. Medication errors or unreconciled medication history; medication noncompliance
  2. Lack of proper follow up care and timely doctor’s appointments after discharge
  3. Falls
  4. Gaps in post-hospital services/lack of support
  5. Infections & pneumonia
  6. Failure to spot and address red flags about the condition
  7. Failure to follow discharge orders/difficulty understanding or not being given discharge instructions

What is the harm of rehospitalizations?

  • Patient safety and comfort
  • Stress on patient and caregivers/family
  • Higher risks and mortality rates
  • Costs–both to the system/payors and to the patient in copays, services, etc. Additionally, a patient who suffers repeated rehospitalizations is more likely to need a higher level of care and often ends up in a care facility, which comes with both emotional and monetary costs.

An Effective Hospital Readmissions Reduction Program

To build an effective hospital readmissions reduction program, EasyLiving looked at 1. Data and especially the top factors causing rehospitalizations 2. Evidence-based solutions (especially as powered by technology to address important gaps).

Our Safe at Home hospital readmissions reduction program builds a targeted approach to the client based on their needs. It uses evidence-based interventions, with an overall approach of care-managed in-home support enabled by care technology.

Along with our hospital readmissions reduction program to support any client returning from the hospital, we offer targeted programs for several key conditions that tend to be susceptible to rehospitalizations:

Congestive Heart Failure

COPD (Chronic Obstructive Pulmonary Disease)



EasyLiving’s Hospital Readmissions Reduction Program: Addressing Common Causes of Rehospitalizations

Medication errors, noncompliance, reconciliation issues

A key component of our hospital readmissions reduction program is reconciling medications. Often, upon discharge, a patient gets new medications. Yet, no one has ensured they don’t overlap or conflict with previous medications. Or, the patient does not realize what medications are replacements and improperly doubles up or takes something no longer appropriate. We check for this and use tracking software to reconcile medications and communicate amongst providers, clients, and caregivers/family. We provide medication assistance solutions as well, and monitor for problems.

Lack of proper follow up care and timely doctor’s appointments after discharge

EasyLiving’s shared calendar system helps keep track of follow up care so nothing gets missed. We also provide transportation to appointments, along with care coordination.


Our Fall Prevention interventions identify and reduce fall risks. These simple, but often overlooked, solutions have resulted in a significant reduction in falls, injuries, and related rehospitalizations.

Gaps in post-hospital services/lack of support

Our hospital readmissions reduction program is all about providing the necessary support. This includes patient and family education, care manager oversight, and all the services needed to stay safe and healthy. For example, a patient recuperating needs the right nutrition (and hydration), but too often this isn’t accounted for at discharge. An elder returns home and needs to figure out how to go grocery shopping and prepare meals when they’re just out of the hospital.

Therefore, when we create our care plan, we don’t overlook these “non-medical” services–without which all the best medical services in the world will fail. The importance of such “social determinants of health” continues to be better recognized. Not addressing them leaves big gaps that lead to many rehospitalizations.

Infections & pneumonia

Our hospital readmissions reduction program specifically targets signs of infection and pneumonia, since they are such common problems. We build in monitoring with our care technology, so any issue can be addressed immediately. Of course, our plan also includes proactive steps to reduce the risks. For example, infection control measures, keeping the person’s head raised in bed, following eating/swallow protocols, etc.

Failure to spot and address red flags about the condition

Our care technology addresses this problem head on. We use daily and weekly assessments of key indicators so we spot any trouble on the horizon.

Failure to follow discharge orders/difficulty understanding or not being given discharge instructions

Care management focuses on taking such issues out of the equation, especially during key transitions like hospital discharge. We are there as your advocate at the time of discharge and beyond, to be sure you and your caregivers understand everything, have been given the information and tools you need, and to check up on progress.

Hospital Readmissions Reduction Program Results

EasyLiving’s rehospitalizations rate for the last 30 days is 1.4%. While during that same period, the national average was 15.6% and the local rehospitalizations rate was 15.9%.

Additionally, ER costs over 90 days for home care patients was $13,012 vs. $20,325 for patients who did not receive home care services.