Table 1.

Possible Causal and Modifiable Factors Associated with Readmission

Factor	Potential Intervention
Patient
Cognition	Screening for cognition at discharge. Increase support at home. Additional use of a surrogate in explaining discharge instructions.
Depression	Screening for depression during the hospitalization and at discharge. Treatment of depression. Increased outpatient support to monitor depression.
Health Literacy	Screening for health literacy. Involvement of hospital staff, social support network, and outpatient primary care physician to reinforce discharge instructions.
Support at Home	Assess home support for patient. Increase phone call and home aid support following discharge for those with inadequate support
Functional Ability	Assess physical function throughout hospitalization and at discharge. Involve physical therapy early in the hospitalization and post-discharge.
Financial Assets	Assess ability to pay for medications and transportation to follow-up appointments. Work with social work on improving access.
Chronic Disease (i.e. Congestive Heart Failure)	Improve patient education of disease and medications. Increase home support to monitor health status. Increase frequency of outpatient visits as needed.
Primary Care Physician
Patient - PCP Interface	Reinforce so the patient understands disease process (e.g. heart failure exacerbation triggers), will take medications started during hospitalization, and recognizes early precipitants of hospitalization.
PCP-Hospitalist Interface	Encourage adequate communication about past medical problems and individualized issues pertinent to care plans.
Quality of Outpatient Primary Care	Adhere to guidelines of care recommended by advisory standards. Ensure patients receive optimal outpatient care.
Medication Reconciliation	Ensure that admission and discharge medication reconciliation is perfect. Update outpatient medication list with inpatient medication changes.
Follow-up of Pending Tests	Create trigger system of pending tests for recently discharged patients.
Access to rapid follow-up appointments	Incentivize physicians of recently discharged patients to offer follow-up appointments in 1 week or less.
Hospitalist
Patient- Hospitalist Interface	Improve communication with patient on how to access physicians if residual post-discharge questions.
Hospitalist- PCP Interface	Encourage adequate communication of hospital course and post-discharge plan.
Quality of Inpatient Hospital Care	Ensure patients receive optimal inpatient care. Assess patient clinical stability and determine optimal time for discharge.
Written Discharge Instructions	Create easily understandable discharge instructions. Install checks to limit human errors. Ensure patient has copy on discharge
Verbal Discharge Instructions	Learn to use teach-back methodology to assess patient understanding of discharge instructions. Work to eliminate multiple sources (e.g. consulting physicians, nurses, therapists) giving conflicting verbal discharge information.
Medication Reconciliation	Utilize outpatient physician notes and pharmacy records to corroborate patient lists. Ensure that admission and discharge medication reconciliation is perfect.
Pending Tests	Ensure discharge summary includes information and is communicated to PCP for follow-up in timely manner.
Home services	Arrange for home support and nursing services to assist with patients needs post-discharge. Assess whether the patient knows of pending home services and means of contacting services if they do not occur.