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Hospital Readmissions

Key Facts

  • Critical to patient-centered care is ensuring patients have the tools and resources to recover at home and avoid returning to the hospital.
  • Patients are most vulnerable for readmission to the hospital immediately following discharge when they are often trying to follow new medication directions or make lifestyle changes. 
  • Factors outside of quality hospital care or discharge transitions, such as access to community resources and family support, can impact a patient's likelihood of readmission.
physician holding clipboard and wearing stethoscope

What is this measure?

Johns Hopkins Medicine hospitals track the number of patients with unplanned readmissions to the hospital within 30 days of being discharged.

Readmission to the hospital could be for any cause, such as progression of disease, complications or developing a new condition. Unplanned hospital readmission may or may not be related to the previous visit.

Hospitals submit readmission rates for Medicare patients to the Centers for Medicare and Medicaid Services (CMS) for the conditions of heart attack, heart failure and pneumonia. CMS compares a hospital’s 30-day readmission rate to the national average for Medicare patients.

How does Johns Hopkins Medicine perform?

better than average
Better than average

Adjusted readmission is lower than U.S. national rate.

meets average
Meets average

Adjusted readmission is about the same as U.S. national rate or difference is uncertain.

worse than average
Worse than average

Adjusted readmission is higher than U.S. national rate.

View readmission rates for:
 July 2011 - June 2014July 2012 - June 2015July 2013 - June 2016July 2014 - June 2017
U.S. National Rate17.0%Not availableNot available16.0%
The Johns Hopkins Hospitalmeets average
Meets average
Not availableNot availableworse than average
Worse than average
Johns Hopkins Bayview Medical Centermeets average
Meets average
Not availableNot availablemeets average
Meets average
Sibley Memorial Hospitalmeets average
Meets average
meets average
Meets average
meets average
Meets average
meets average
Meets average
Suburban Hospitalmeets average
Meets average
Not availableNot availablemeets average
Meets average
Howard County General Hospitalmeets average
Meets average
Not availableNot availablemeets average
Meets average

Why is it important?

Critical to patient- and family-centered care is ensuring patients have the tools they need to recover at home and avoid the need to return to the hospital. This measure of 30-day readmissions may show how well a hospital is educating Medicare patients about their conditions, preventing complications and providing comprehensive care transitions at discharge.

However, some readmissions are unavoidable. Factors outside the quality care of a hospital and discharge transitions can impact a patient’s likelihood of readmission, such as access to family support and community resources.

What is Johns Hopkins Medicine doing to continue to improve?

Patients are most vulnerable for readmission immediately following discharge when they are often trying to follow new medication directions, make lifestyle changes and manage follow-up appointments. Johns Hopkins Medicine comprehensively prepares all patients before discharge and offers a variety of programs for patients who need extra support when going home.

Preparing for Discharge

Some Johns Hopkins Medicine hospitals have nurses called transition guides, who meet patients while in the hospital and then visit the patient at home for up to 30 days. These nurses ensure that patients have their medications and are taking them correctly. They also answer any questions and review important instructions, like when to call the doctor.

Many Johns Hopkins hospitals also have special pharmacy programs that provide bedside delivery for discharge medications. Pharmacists can visit patient rooms for extra instruction about high-risk conditions and the drugs used for treatment.

Helping with the Transition Home

Johns Hopkins Medicine has a Patient Access Line to support the care transitions of patients over the phone. Eligible patients receive a follow-up phone call from a nurse through the Patient Access Line within two days after being discharged from the hospital.

The nurse asks questions about how the patient is feeling, assesses if the patient is correctly taking medications and reminds the patient of upcoming appointments. The nurse then consults with the clinical team to address any concerns or find more resources.

Frontline Perspective

Kathy Ward Kathy Ward is the Manager of Case Management  in the Department of Medicine at Johns Hopkins Bayview Medical Center. Her primary responsibility is to coordinate patients' services while they are hospitalized and the transition of care once they are discharged.

Kathy Ward, B.S.N., R.N., A.C.M., C.C.M.
Manager of Case Management, Johns Hopkins Bayview Medical Center

“The best part of my job is forming relationships with patients and their loved ones, and working with them to successfully transition the patient from the hospital to their home.

Patients who are discharged from the hospital are often at a high risk of being readmitted. This can be due to them having multiple health conditions, being uninsured, not having support systems in place or having a low level of literacy.

To make the patient’s transition plan from the hospital successful, I conduct a full medical, social and financial assessment, and coordinate with several key players, including home health services, financial counseling and community agencies.

I work to understand the motivations of my patients, educate them and, where needed, offer a ‘bundle of services’ for the highest-risk patients. I use data to understand how these different interventions can help reduce the risk of my patients being readmitted.

The one thing I will never do is ‘write a patient off.’ I love that I work as an advocate for my patients and can always customize or change and implement a new plan, if needed.”

How can patients and families support safety?

Understanding how to manage your health conditions is an important part of leaving the hospital, including knowing about any medications, dietary restrictions or physical activity recommendations. Talk to your care team if you or a loved one has questions during the transition or after discharge.