20% of admissions to internal medicine departments in Israel are readmissions within one month.
When patients are discharged from the hospital, they receive a discharge summary and instructions for follow-up care.
However, scheduling an appointment with the appropriate physician and ensuring that information is transferred from the hospital to the treating physician at the HMO (Israeli health fund) remain the responsibility of the patient.
How many patients actually understand the bureaucracy involved and know how to navigate the process correctly? Patients are expected to convert the hospital’s instructions into the appropriate referrals and funding authorizations from their HMO; explain to their HMO physician what treatment they received and the basis for the decisions made; obtain the appropriate medications through the HMO; and arrange follow-up tests at the frequency and level of urgency specified by the hospital, including blood tests, imaging, and other examinations that may not be available through the HMO within the required timeframe.
It is therefore clear that much of the responsibility for ensuring a successful transition from hospital to community care currently rests on the patient’s shoulders. This may help explain why one in five patients admitted to internal medicine departments had already been hospitalized during the previous month.
Research shows, however, that this is not inevitable. Changes to processes and infrastructure in both hospitals and community care can improve outcomes for patients and benefit the healthcare system as a whole.
Israel and healthcare systems around the world are grappling with the challenge of hospital readmissions. Data published by the Israeli Ministry of Health in 2013 show that:
- Approximately 20% of all admissions to internal medicine departments are readmissions within one month, and 8% are readmissions within one week. These figures have remained consistent over the years, with no significant trend of improvement.
- Readmission rates increase with age. At age 75, 25% of admissions are readmissions within one month. The likelihood of readmission to an internal medicine department also increases with the length of the index (initial) hospitalization.
- When the measurement period is extended, patients admitted to an internal medicine department are 2.42 times more likely to be hospitalized again within the following six months than those with no previous hospitalization.
- Patients with certain conditions – particularly malignancies, renal failure, chronic obstructive pulmonary disease (COPD), and heart failure – are at increased risk of readmission (1). This raises an important question: is there truly significant potential to reduce readmissions, or are they an inevitable consequence of disease progression?
- No correlation was found between the number of hospital beds and the readmission rate.
There is no doubt that hospital readmissions carry a significant cost – from the impact on patients’ health and well-being to broader measures of public and economic efficiency. Healthcare systems around the world are therefore concerned with both the extent of readmissions and the ways in which they can be prevented.
Estimates in the literature suggest that between 9% and 50% of readmissions may be preventable, with a median estimate of 30% (2,3). Most prevention strategies focus on the infrastructure and processes required to ensure effective continuity of care across acute-care and community healthcare providers.
Who Is Responsible for Continuity of Care?
Continuity of care refers to the process through which patients move between inpatient care settings and the community, and back again. Patients who have completed the acute phase of their illness often require a structured handover to community care – to one or more healthcare providers capable of developing and implementing the appropriate ongoing treatment plan.
It is well established that improving continuity of care contributes to better medical care, reduces costs, and increases satisfaction among both patients and healthcare professionals (10). Without effective continuity of care, the risks of readmission, medical complications, and increased healthcare expenditure all rise.
The quality of continuity of care depends, among other factors, on the relationship between the organizations involved in the process – hospitals and community healthcare providers.
HMOs and hospitals are two major components of the Israeli healthcare system and operate, to some extent, within a supplier-customer relationship: HMOs pay hospitals for the services provided to their members. Hospitalization represents a substantial share of HMO expenditure, with inpatient care accounting for 41% of HMO operating expenditure in the community sector (4).
The Ministry of Health has a strong interest in ensuring continuity of care, from both a clinical and a public-economic perspective, and serves as the regulator in this area.
At the same time, the Ministry of Health owns 11 public hospitals in Israel. In other words, on the one hand it sets policy, while on the other it also carries operational responsibility. This dual role has a significant impact on the relationship between HMOs and hospitals, placing the Ministry at the center of the conflict while effectively holding both ends of the process.
Between 2011 and 2013, the Ministry of Health introduced an incentive program for HMOs designed to encourage them to reduce hospital readmissions, with the goal of lowering the rate from 20% to 17% (representing estimated annual savings of NIS 300–400 million).
To support this goal, the Ministry allocated NIS 40 million to be distributed among HMOs that succeeded in reducing readmissions by 10% in 2012 and 20% in 2013 (5). However, at the end of the period, the Ministry determined that none of the HMOs had achieved the target.
In the United States, by contrast, where the healthcare system differs from Israel’s public healthcare model, a mechanism imposing financial penalties on hospitals for readmissions was introduced in 2010. A study examining the impact of this approach included 48 million hospitalizations and demonstrated a significant reduction in readmission rates – approximately 15% on average (6).
Returning to Israel, when we examine the process through which patients move from acute inpatient care to continued treatment in the community, we find that most of the responsibility for coordinating, implementing, and ensuring continuity of care falls on the patient.
Although all HMOs have established internal units intended to support continuity of care, many patients still encounter difficulties during the transition from hospital to community care. These difficulties often stem from gaps in the processes and infrastructure required to receive patients back into the community and may ultimately lead them to return to the emergency department when another problem arises.
The challenges involved in transitioning back to community care may be bureaucratic, such as the time required to convert prescriptions or referrals and the availability of appointments in the community, or purely clinical, such as understanding and implementing the instructions provided by the hospital.
Effective continuity of care, supported by appropriate infrastructure, processes, measurement, and incentives in both hospitals and community healthcare settings, can create the change needed to reduce hospital readmissions.
Implementing tools to predict readmission risk and identify patients whose readmissions may be preventable would allow HMOs to focus their processes and resources on patients for whom intervention can make a meaningful difference.
- Information sharing between hospitals and community care, and vice versa. Israel has made considerable technological progress in this area, and a substantial amount of information is now shared and accessible. Nevertheless, there is still a long way to go before every citizen has a single, comprehensive medical record – one that follows the patient between HMOs and, of course, between acute-care settings and community care. Such a record would enable genuine continuity in diagnoses, medication management, and the development of an appropriate treatment plan.
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Discharge planning in the hospital. This should include assessing the patient’s needs before discharge home, with particular attention to functional needs; providing guidance to patients and, where necessary, to family members or caregivers; reviewing the patient’s medications and updating them as needed; transferring information to the next healthcare provider within the hospital or coordinating care with community providers; and conducting follow-up through home visits and/or telephone calls after discharge.
Intervention processes should also be established to bridge the transition between hospital and community care. Each HMO has a unit that serves as a bridge for patients moving from hospital to community care and is responsible for coordinating continuity of care in practice.
These units should implement processes and tools aimed at reducing and preventing readmissions. These may include rapid conversion of prescriptions and referrals (preferably before the patient is actually discharged) scheduling specialist appointments and bringing them forward when necessary, and ensuring a complete handover to the next community healthcare provider responsible for managing the patient’s ongoing care.
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Timely follow-up. The optimal timing for a follow-up appointment with the patient’s community physician after discharge is not known. Numerous studies have examined the relationship between the timing of the first community follow-up appointment and hospital readmissions, and most have demonstrated lower readmission rates among patients whose follow-up appointment was scheduled at the time of discharge (7).
In addition, 50% of patients who require readmission within 30 days of discharge have not yet been seen by a community physician (8). However, a large retrospective study examining nearly 5,000 discharges from Mayo Clinic hospitals found no association between the timing of the post-discharge follow-up appointment and hospital readmission (9).
Processes and Infrastructure in Community Care
As noted above, determining who is responsible for ensuring continuity of care is a fundamental issue in preventing hospital readmissions. HMOs must therefore implement appropriate processes and tools within community care as well.
Resolving bureaucratic barriers, ensuring the availability of specialist appointments, and converting prescriptions and referrals must continue even after the dedicated coordination unit is no longer directly involved in the patient’s care.
Once these processes have been implemented, they should be supported by clear objectives, measurement, and incentives for all parties involved:
- Process effectiveness metrics – for example, the percentage of discharged patients proactively contacted within one week; the percentage whose readmission risk is assessed by a community nurse or physician; and the percentage of high-risk discharged patients whose follow-up recommendations are actually implemented, including prescriptions filled, referrals completed, and tests performed.
- Performance metrics – actual readmission rates among the intervention group. Multidisciplinary units serving complex patients, such as the home hospitalization units currently operated by HMOs, can play an important role. These units can also implement a one-month prevention program until the patient (often someone with a high burden of illness) is stabilized, before responsibility is transferred back to the primary community clinic.
- Monitoring high-risk patients, including patients with COPD and CHF – a process already implemented by several HMOs.
- Patient education and the patient’s ability to help prevent readmission. This is an important area that has not yet been studied on a large scale. It is particularly relevant for patients with chronic conditions, especially those with heart failure and chronic obstructive pulmonary disease, who are at particularly high risk of readmission. It is estimated that in these cases, educational interventions may reduce readmissions by as much as 40% (10).
In summary, as the population ages, hospital readmissions will place an increasing burden on healthcare systems in Israel and around the world. Reducing readmission rates by even a few percentage points could generate significant savings in money and time, reduce morbidity, and materially improve the quality of healthcare.
The question of who is responsible for coordinating and implementing continuity of care in the community remains a key challenge for HMOs and the Ministry of Health. Shifting responsibility for parts of the solution from the patient to community healthcare providers and hospitals, redesigning processes at critical transition points, and introducing proactive HMO intervention beginning at the discharge stage could all play a key role in preventing the next hospital readmission.
