Woman meeting with doctor


Readmissions occurring more than a week after discharge may be the result of patients’ inability to access appropriate outpatient care, according to a study published in the Annals of Internal Medicine.

Researchers found that hospitals, rather than outpatient clinics, were more likely the ideal location to prevent early readmissions (within one week of discharge). Outpatient clinics, however, were more likely than hospitals to be considered ideal sites to prevent readmissions after the first week following discharge. Interventions offered by outpatient facilities to prevent readmission include appointment availability within an appropriate timeframe for patient monitoring and symptom management by primary care clinicians.

“Our findings suggest that the 30 days following hospital discharge are not the same with regard to what influences outcomes for sick patients, and that the current model oversimplifies this high-risk time,” said lead researcher Kelly L. Graham, MD, MPH, Director of Ambulatory Residency Training at Beth Israel Deaconess Medical Center and an instructor in medicine at Harvard Medical School.

“One potential unintended consequence of this is that outpatient environments have not been involved in efforts to manage this high-risk timeframe, which results in poorly coordinated care and worse outcomes for our patients.”

Click here to read more about the study.

To address these issues in our region, Great Plains QIN is focusing on processes of care at a community level to engage providers and stakeholders across the continuum of care. Click here to learn more about our care coordination work and how you can become involved. Two recent webinars hosted by the Great Plains QIN examined key strategies to help health systems and communities implement complex care teams utilizing technology, nontraditional workforce and patient-stated goals. Recordings of Improving Care Coordination by Working with Super-Utilizer Patients and the follow-up coaching call are available on the Great Plains QIN website.