Table 2

Patient, provider, RN case managers’ response to the following question: Is there anything that could have been done differently to have eliminated or minimised this return admission?

Patient response%Provider response%RN case managers response%
No modifiable cause identified42No modifiable cause identified71No modifiable cause identified41
System: discharged too early21Patient: adherence Issues13System: inadequate education prior to discharge17
System: earlier f/u appointment with a doctor7Patient: did not present to f/u5System: inadequate postdischarge f/u care/appointment14
System: SNF/LTAC issue7Patient: psychosocial4System: inadequate assessment postdischarge level of care14
System: needed more help with ADLs at home7Other3System: discharged too soon12
System: other5Patient: patient did not accept HHS2Patient: lack of adherence or understanding medications/therapies10
System: medication issue4Patient: financial1Patient: psychosocial3
System: HHS issue3System: discharged too early/HHS issues2System: inadequate medication management/reconciliation3
System: equipment issue2Patient: no show to f/u3
System: lack of wound or insulin supplies2Patient: financial issues2
System: lack of timely exchange of healthcare information to PCP<1
  • Providers (71%) were more likely than patients (42%) or RN case managers (40%) to identify ‘no modifiable cause’ that could have prevented readmission.

  • The RN case managers could provide more than one answer for patient and system issues so numbers do not add up to 100%. ADL, activity of daily living; f/u, follow-up; HHS, home health services; LTAC, long-term acute care; PCP, primary care provider; SNF, skilled nursing facility.