Rethinking the Role of Primary Care in Reducing Hospital Readmissions

It takes a team effort to reduce potentially preventable hospital readmissions. Patients leaving the hospital need tailored education about how to take their medications, whether to get home care services, and when to follow up with their primary care physician.

Despite modest progress, readmission rates remain high. And while some readmissions are appropriate and unavoidable, every readmitted patient has his or her life interrupted and must face the risks of hospital-acquired infections and other patient safety risks.

To date, strategies to reduce readmissions have largely focused on enhancing practices and processes within hospitals. Indeed, these vital initiatives have had significant impact. But as we look for additional ways to build a healthcare system that delivers 21^st century healthcare, AHRQ recognizes that something has been lacking: a systematic effort to reduce readmissions by enhancing the role of primary care.

A new AHRQ report—Potentially Preventable Readmissions:  Conceptual Framework to Rethink the Role of Primary Care—aims to re-examine this dynamic.   

AHRQ’s previous efforts to reduce readmissions have included development of the RED (Re-Engineered Discharge) toolkit, a comprehensive discharge planning process that emphasizes the importance of patient education and a post-hospital care plan. Another AHRQ-funded effort, Designing and Delivering Whole-Person Transitional Care, identifies ways evidence-based strategies to reduce readmissions, which can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.

Now, with the new conceptual framework, we are rethinking the role of primary care in preventing hospital readmissions by considering the “integrator” role that primary care can play within the health system.  We believe there is a need for new care delivery models that engage primary and specialty physicians, hospitals, and other partners in providing complete and coordinated care.

Expanding primary care’s role to reduce readmissions and adverse events may seem both logical and necessary. But hospital processes and systems, potentially due to financing regulations and incentives, are often designed in ways that don’t involve primary care practices in a timely or effective way, according to the report. 

For instance, many practices aren’t notified when their patients have been admitted or readmitted to the hospital or emergency department.  Follow-up appointments with a patient’s primary care physician aren’t often made within a 14-day window, the time period when many readmissions occur.  A lack of shared care plans, a common electronic medical record, and payments for care coordination are additional—and significant—barriers.

In short, primary care brings potential real benefits to delivering care to newly discharged hospital patients, but there are currently challenges to realizing this potential.  So, what’s the best approach to involving primary care in a more meaningful way?  The report’s authors put that question to a diverse group of healthcare providers, community agencies, and patients.

It drew on the expertise of more than 130 staff in nine primary care clinic sites, as well as 14 community agencies to better understand new ways of preventing readmissions.  These agencies represented services such as transportation, visiting nurses, mental health, substance abuse, and aging services.  And finally, patients themselves weighed in on the potential breakdowns that can occur during the transition from the hospital to the primary care setting.   

Their views helped develop new principles about the role that primary care should play in the hospital post-discharge care process by:

• Serving as the key integrator of post-discharge patient care.
• Handling post-discharge follow-up visit(s) differently from a typical office visit.
• Using a team-based approach to ensure high-quality care transitions, spanning the hospital admission to post-hospital visit periods.
• Developing a systematic approach to information exchange with hospitals, post-acute care agencies, and behavioral and social support agencies.
• Addressing whole-person needs in a patient-centered way.

More research is needed to test these principles, but we’ve long known that preventing hospital readmissions requires a team-based effort.  While many of these principles are not new ideas, we believe that with changes in the healthcare ecosystem, the time may be right to make progress on this important issue. 

David Meyers, M.D., is AHRQ’s Deputy Director and a board-certified family physician.  Jeff Brady, M.D., M. P. H., is Director of AHRQ’s Center for Quality Improvement and Patient Safety.

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