The Revolving Hospital Door

While I was writing this editorial on hospital readmissions, my 90-year-old mother was admitted to her local community hospital for a severe circulation problem and leg sores. After 10 days of hospital-induced immobility and a series of inconclusive diagnostic tests, she was discharged home to her Buffalo, NY, apartment where she lives alone. Her discharge plan consisted of a request that she contact her vascular specialist to schedule weekly follow-up visits for management of her leg sores, and advice from a hospital physical therapist to walk more to reverse her severe deconditioning.

Luckily for my mother, she has a son and family and friends who live close by to provide essential support services—and another son who happens to know many physical therapists in the area who could be engaged to provide her with the postacute care she needs, both to return to her pre-hospital level of function and to reduce the risk of a fall that could land her back in the hospital. But my mother's experience is a clear example of the all-too-common “silo of care” that exists when the patient leaves the acute care hospital: there is little or no integration between acute care and the transition to postacute care; and short-term hospital readmission, or worse, frequently results.

Preventable readmission of patients within a month of acute care hospital discharge is considered one of the nation's major drivers of high medical costs, accounting for an estimated $17 billion annually in Medicare spending alone.¹ And returning to the hospital soon after discharge not only is costly and a sign of poor care, but can be deeply troubling for patients who think they are on the road to recovery at discharge only to discover that they need help to achieve a safe and successful transition back home.

The almost 20% readmission rate of Medicare patients led the Centers for Medicare and Medicaid Services (CMS) to implement policies that limit reimbursement for 30-day unplanned readmissions and thus place hospitals with high readmission rates at financial risk.¹ Partly in response to this CMS initiative, reducing the 30-day hospital readmission rate has become a major quality improvement priority for hospitals.² But as my mother's case illustrates, much more needs to be done to move beyond the “silo of care” model to provide the level of coordinated and integrated care that people need.

My mother's recent experience highlights some of the reasons for the high rates of 30-day hospital readmissions in the United States and the important role that physical therapists and other rehabilitation professionals can play in improving hospital discharge planning and the transition to postacute care. The reasons for 30-day hospital readmission are complex and multifaceted. According to existing evidence, key risk factors include^3,4:

• Medical complexity

• Age

• Comorbidities

• Access to community care

• Hospital length of stay

• Available social support

• Patient's functional limitations

In a nationally representative cohort of almost 8,000 community-living older adults, researchers showed that the adjusted risk of 30-day hospital readmission progressively increased as the degree of functional limitation increased, from 13.5% of older adults who have no functional limitation to 18.2% of older adults who are dependent in 3 or more activities of daily living (ADLs).⁵ Rehabilitation professionals are uniquely qualified not only to assess a patient's functional limitations during a hospital stay, but to develop treatment goals beyond the hospital setting and facilitate referrals to postacute care providers when needed.

Currently, physical therapists in the United States are not routinely included in care transition efforts beyond recommendations of discharge location,³ despite the growing evidence that they can play an important role in reducing rates of 30-day hospital readmission.^6–9 Care transitions are an increasingly important part of policy initiatives such as the CMS bundling payment programs, and short-term hospital readmission is a common quality indicator within these initiatives. Physical therapists need to advocate for their role in reducing short-term hospital readmission through improvements in post–hospital discharge management of patient function.

What steps could physical therapists take to assume a stronger role in the treatment of hospitalized persons within care transition teams? In a thoughtful perspective on the role of physical therapists in reducing hospital readmissions, Falvey and colleagues³ cite 3 important roles that physical therapists could play:

• Educate their clinical colleagues and hospital administrators on the important role that rehabilitation professionals can play in discharge planning, drawing on the growing evidence of their value and impact in this area.

• Become intimately involved in the design and implementation of research within and across hospitals and medical centers to evaluate and then disseminate the impact of different care transition models aimed at reducing 30-day hospital readmission that involve rehabilitation during and after the hospital stay. Kadivar and colleagues' evaluation of the positive role of physical therapist involvement in hospital discharge planning teams published in the November issue of PTJ is an excellent example of this type of research.⁶

• Work with their institutions to adopt and utilize assessment tools that enhance communication across professions regarding the functional deficits and discharge needs of patients as they transition from acute to postacute care. Given the short lengths of stay in acute care hospitals and the focus on assessing patients to make discharge recommendations and manage postdischarge function, measurement tools that enhance the accuracy of discharge recommendations at an early stage could prove to be indispensable. Assessment tools (full disclosure—tools such as the one developed by my colleagues and me¹⁰) are available that can be used not only within the hospital setting but across postacute care venues as well.

Hospitalizations are stressful for patients and families and can be dangerous to a patient's long-term health. Although some hospital readmissions cannot and should not be prevented, acute care hospitals have an obligation to engage in activities that can lower the current high rate of short-term readmissions. Rehabilitation professionals can and should play an important role within interdisciplinary teams in improving the hospital discharge planning process and in coordinating with postacute care and primary care providers to reduce the alarming rates of short-term hospital readmission.

• © 2016 American Physical Therapy Association