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 identified	42	No modifiable cause identified	71	No modifiable cause identified	41
System: discharged too early	21	Patient: adherence Issues	13	System: inadequate education prior to discharge	17
System: earlier f/u appointment with a doctor	7	Patient: did not present to f/u	5	System: inadequate postdischarge f/u care/appointment	14
System: SNF/LTAC issue	7	Patient: psychosocial	4	System: inadequate assessment postdischarge level of care	14
System: needed more help with ADLs at home	7	Other	3	System: discharged too soon	12
System: other	5	Patient: patient did not accept HHS	2	Patient: lack of adherence or understanding medications/therapies	10
System: medication issue	4	Patient: financial	1	Patient: psychosocial	3
System: HHS issue	3	System: discharged too early/HHS issues	2	System: inadequate medication management/reconciliation	3
System: equipment issue	2			Patient: no show to f/u	3
System: lack of wound or insulin supplies	2			Patient: financial issues	2
				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.