Untimely Info Sharing Inflates Nursing Home Rehospitalizations

Delayed discharge summaries may play a large role in why so many Medicare patients are rehospitalized after being discharged to nursing homes, according to research published in the Journal of General Internal Medicine.

The study, funded by the University of Wisconsin Health Innovation Program and the National Institutes of Health, followed 489 Medicare patients who were sent to nursing homes after being discharged from the hospital.

About 20% of Medicare patients are rehospitalized within 30 days of discharge, reportedly at an annual cost of about $17 billion, and this could result from discharge summaries that either lack details or are inaccurate by the time they’re sent to nursing homes, according to the researchers.


Currently, each patient is supposed to have a discharge summary created within 30 days of their discharge, per Joint Commission rules, the study says. However, researchers found that this 30-day window may be “too broad and may contribute to poor discharge documentation quality.”

“Poor discharge summary documentation of actionable components, such as diet and therapy orders, has the potential to directly impact the patient’s plan of care/admission orders within the sub-acute care facility and may increase the risk for rehospitalization, excess sub-acute care nursing and therapy staff work load, and other negative post-hospital outcomes,” the study reads.

Discharge summaries are a key communication tool during care transitions, the study’s authors say, but those examined within the study “frequently omitted critical expert-recommended components, especially those within the actionable categories of ‘future plan of care’ and ‘name and contact information.'”


This poses challenges and problems for recently-discharged patients, as nursing home workers may not be able to provide necessary care without all pertinent information.

“Experts suggest that care during the hospital discharge and early post-hospital period may be critical in preventing at least a portion of these rehospitalizations,” said lead author Amy Kind.

The impending impact of healthcare reform may affect hospital readmissions through the Rehospitalization Reduction Act. The act may prompt hospitals to provide patient health care information to nursing homes more quickly and reliably, as it will penalize hospitals if their rehospitalization rates for patients with congestive heart failure, heart attacks and pneumonia are above a certain level, starting in 2013.

View the research, “Provider Characteristics, Clinical-Work Processes and Their Relationship to Discharge Summary Quality for Sub-Acute Care Patients,” here.

Written by Alyssa Gerace