Primary care physicians are critical in addressing health inequities in readmissions and long-term care

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The average hospital readmission rate across the United States is approximately 14.6%, ranging from as low as 11.2% to as high as 22.3% in some areas. With costly impacts on health care systems and patients, there has been a concerted effort in the last decade to lower readmissions in an effort to minimize the cost of care and improve patient outcomes overall. This includes amplifying the communication and collaboration among physicians, specialists and care team members, and particularly emphasizing the role of the primary care physician (PCP) in leading the team to better patient outcomes.

Ahzam Afzal, PharmD
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PCPs are in a unique position to help prevent hospital readmissions. They coordinate a patient’s care, are often the first point of contact when a patient is experiencing health problems, and usually have a better picture of care journeys with more touchpoints and communication with patients or their families. They are integral to identifying deterioration and worsening of conditions and intervening to avoid readmissions or even death. PCPs are also able to leverage their knowledge, communication and position in a patient’s care journey to minimize the impact of health care inequities that continue to challenge the health care system.

Health care inequities in readmission rates

Hospital readmission rates can be greatly impacted by race, ethnicity, socioeconomic status and more. One study found that the readmission rate for Black patients was as high as 19.4%, almost 5% higher than the national average, compared to the 13.8% rate of White patients in the same study. Another study found that Black Medicare beneficiaries had a 37% higher chance of getting readmitted to a hospital or an acute care setting than White beneficiaries. Overall, the National Institutes of Health found that patients who identified as Black had the highest readmission rates compared with all other racial and ethnic groups. That is not to minimize the challenges among patients who identified as Latino, Asian, American Indian or Alaska Native, and others who had higher readmission rates than White beneficiaries.

Additionally, living in a disadvantaged neighborhood is associated with higher readmission rates. Although Medicaid eligibility at a certain poverty level diminished the differences in readmission rates slightly for Black patients, socioeconomic status has been linked to worse surgical outcomes and lower health care utilization, which can greatly impact the data as well as patients and their outcomes. All of these factors can put some of our most vulnerable patient populations at a disadvantage when transitioning from an acute care setting to a long-term or post-acute care setting, but primary care physicians can help fill in the gaps in care exacerbated by inequities.

PCPs, collaboration and communication

Transitions of care, especially when a patient is being transferred from an acute care setting to a post-acute or long-term care facility, present the greatest risks for patients, and those with chronic illnesses are most at risk. A seamless transition of care between care settings is crucial to ensuring positive outcomes and avoiding hospital readmissions or worsening conditions. The efforts of PCPs in managing complex and chronic care effectively can go a long way toward ensuring the continuity of quality care for higher-acuity patients. In fact, studies have shown that having PCPs involved and engaged in the management of chronic or complex conditions can lower readmission rates significantly for patients recently discharged. To address current challenges and shape a better future for care coordination, PCPs must leverage all the tools they have at their disposal to keep a close eye on patients entering and leaving acute and post-acute care settings.

PCPs at the forefront of preventing readmissions

There is increasing recognition in the medical community about the crucial role of primary care in reducing hospital readmissions. One study for the U.S. Agency for Healthcare Research and Quality recommended that primary care clinicians should have a central role and effectively “own” the care transition process, citing the fact that hospital-based efforts have modestly reduced readmission rates. The study recommended that during care transition efforts, the primary care clinician leads multifaceted interventions to address gaps — including medication management, patient education and home care — and that these efforts should be implemented early in the care journey. It also recommended that primary care practices consider developing formalized relationships with hospitals treating their patients, “with a mutual goal of sharing data, identifying high-risk patients, communicating during a patient’s hospitalization and coordinating care transitions processes.” Effective partnerships between primary care providers and community programs that address socioeconomic challenges could also improve quality of care and prevent readmissions among patients facing food insecurity, poor housing or social isolation, the study noted.

Utilizing technology for effective collaboration

Digital technology such as patient portals, remote patient monitoring, telemedicine platforms and advanced analytics can strengthen collaboration and communication between practices and facilities, enabling PCPs to have better visibility into patients’ health status and coordinate timely interventions as needed. These tools and better communication among hospitals, PCPs, specialists and other care team members enable PCPs to identify a care plan for post discharge, track medications and continue follow-ups with patients through telehealth or other patient monitoring software, all of which are crucial to patient progress and satisfaction.

Additionally, PCPs can provide clear and effective communication throughout the care journey, especially during care transitions, to ensure care plans and outcomes are clearly communicated to patients and their families, as well as other members of the care team. PCPs are perhaps better positioned than anyone on a patient’s care team to address the gaps in care that lead to worse patient health outcomes and higher readmission rates. Because of their direct touchpoints with patients and their families, PCPs have greater visibility into their success in treatment and condition management and can lead collaborative efforts between practices and outpatient facilities to reduce hospital readmissions and improve patient outcomes no matter a patient’s race, ethnicity or socioeconomic status.

It’s tragic when a patient with a chronic illness, such as chronic obstructive pulmonary disease, heart disease or diabetes, is discharged from a hospital to a skilled nursing facility, only to be readmitted to the hospital when their condition worsens. Yet with the right care coordination measures, real-time insights and effective communication in place, hospital readmissions are entirely avoidable, even for patients with complex care needs. Seamless, uninterrupted care when a patient is being transferred from the hospital to a skilled nursing facility is vital to keeping that patient’s health on track. As the patient’s strongest health advocate and clinician most responsible for preventive health measures, the PCP is ideally positioned to directly participate in care coordination and lead care coordination during the post-discharge process.

Ahzam Afzal, PharmD, is the co-founder and CEO of Puzzle Healthcare, a nationally recognized company that specializes in post-acute care coordination and reducing hospital readmissions. Under his leadership, Puzzle Healthcare has garnered praise from several of the nation’s top health care systems and ACOs for its exceptional patient outcomes, improved care delivery, and effective reduction in readmission rates.