Case Management

CMW sneak peek: Study shows barriers to reducing 30-day readmissions

Case Management Weekly, January 6, 2010

Results of a nine-month HCPro transition-of-care study, available on, illustrate the efforts of hospitals and SNFs to improve transitions. The study authors interviewed 931 hospitals and SNFs, seeking to better understand the following:

  • Barriers affecting transitions between settings
  • Underlying causes of readmissions 
  • Number of readmissions due to patient noncompliance 
  • Frequency of medication changes for transitioning patients and the potential influence on readmissions 
  • Community-based solutions hospitals and SNFs are piloting to create safer transitions and reduce readmissions

The authors of Reducing Hospital-SNF 30-Day Readmissions: Underlying causes, perceptions and solutions from a disconnected continuum, will analyze the findings during a panel discussion January 28 at the Leadership Summit on Readmissions.

Before you access the full report at, here’s a snapshot of the findings:

  • More than 75% of respondents said better communication between hospitals and SNFs would be highly likely to reduce 30-day readmissions; however, 30% of the hospitals and 36% of the SNFs admitted they do not currently require any dialogue between settings during the transition process.
  • More than 50% of study participants said they most often lack a true picture of the patient’s health during transitions, which contributes greatly to readmission risk. Information is also commonly lacking about medications tried in the previous setting and their ensuing side effects.

To elevate communication, 16% of SNFs began to attend hospital LOS meetings in 2009. At McLean Affiliates in Simsbury, CT, an RN from the SNF conducts an onsite review at the local hospitals to assess medical records and talk to care providers in the acute care setting prior to transitions. Fifty-eight percent of the hospitals and 51% of the SNFs said a consistent drug formulary across settings is very likely to reduce 30-day readmissions. Further supporting the idea that more open formularies may be helpful in transitions, 47% of hospitals and 51% of SNFs said fewer drug formulary restrictions would very likely reduce readmissions.

Check out the January 2010 issue of Case Management Monthly to learn more. You also can discover the benefits of becoming a Case Management Monthly subscriber.

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