1. Title: Assessing Patient Readmission for Improving Quality of Healthcare
Name: Manali Shah
Preceptors: Dolores Van Pelt, Director of Organizational Effectiveness & Karen Hepworth,
Performance Improvement Specialist
Agency: Hunterdon Healthcare
Purpose: To analyze and evaluate patient knowledge about disease and discharge instruction
which can result in and affect hospital readmission
Significance: In 2014, the Center for Medicare and Medicaid Services (CMS) penalized around
2,610 hospitals for high readmission rates, which cost up to $500,000 per hospital (Reardon). In
order to lower the number of readmitted patients, the CMS established the Hospital Readmission
Reduction Program (HRRP), which requires the CMS to reduce payments it gives to a hospital
with surplus readmissions rate (Reardon). Under the HRRP, hospitals with high readmissions
rates have 3% of their financial aid withheld (Brown). A 3% penalty could affect a hospital's
entire profit margin thus providing strong incentive to reduce readmission rates. Therefore,
Hunterdon Healthcare is reevaluating the program and gathering data on factors that contribute
to patients’ readmission, which will hopefully decrease the readmission rate in the future.
Method/Approach: The evaluation will be based on 30-day readmission criteria to analyze
patient’s knowledge on the disease and discharge instructions. A 15 open-ended questions survey
mixed with yes/no responses was designed to ask patients about readmission. For example,
questions such as, “What is your understanding as to why you were readmitted,” and “Do you
feel any of the following contribute to readmission: transport, lack of support, etc,” were asked.
In order to assess the quality of healthcare where changes can be made, 57 patients were asked
questions to determine which factors were repeated among patients. The methodology was to
review 30-day readmission reports, create the questionnaire, interview patients, and compile data
to look for trends. Data was shared with the organizational effectiveness department on a weekly
basis to monitor the effectiveness of the questionnaire.
Outcomes: The data is compiled of patients who vary in ages from late 40s to early 90s, with the
exception of one 3-month old. The data findings show three potential patterns for patient
readmission: 1) 82% of patients are not able to obtain a follow-up appointment with a primary
care physician, 2) the majority of patients (57%) stated that transportation was the primary
reason for readmission, and 3) 70% of patients cannot state the cause. In order to see a possible
decline in the readmission rate, more education on diet and self-care should be provided to
patients and caregivers.
Evaluation: The implementation of changes to the discharge process may reduce readmission,
thus reducing hospital penalties. Hunterdon uses a software system that collects data on
readmissions. The readmissions team monitors this data monthly to see if interventions are

2. working. A drop in readmission rate will determine to what extent the project is successful and if
any changes need to be made.