The numbers are disturbing and disappointingly familiar. According to the federal government, one in five elderly patients winds up back in the hospital within 30 days of leaving. The cost is troubling, too. The readmission of Medicare patients alone costs $26 billion annually, $17 billion of which is spent on return trips that wouldn’t need to happen if patients received proper care during their first visit.

The Centers for Medicare & Medicaid Services calls avoidable readmissions one of the leading problems facing the U.S. health care system, and in an effort to turn things around is now penalizing hospitals with high rates of readmissions for patients with certain conditions.

In America, we should be doing better. We need to pinpoint why this problem persists. What are the human factors behind these numbers?

That is why the Robert Wood Johnson Foundation commissioned a report, “The Revolving Door: A Report on U.S. Hospital Readmissions,” to take a closer look at the issue of readmissions through the eyes of those grappling with the problem. The report is part of our Care About Your Care initiative, devoted to improving the transition from hospital to home.

The report includes up-to-date readmission data and research from the Dartmouth Atlas Project, focusing on states, hospital referral regions, and individual hospitals. It also includes interviews with patients, caregivers, and health care providers who live and work in metropolitan Washington, New York City, and Dallas, conducted by PerryUndem Research & Communication.

Patient Experiences

One of the patients, Barbara, has type 2 diabetes. She found herself in the hospital because her blood sugar was out of control. After being treated, Barbara was discharged, even though she thought it was too soon. Upon departure, she received no new information about how to properly administer her insulin, or how to eat right. A day and a half later, she was back in the hospital. This time, Barbara met with a dietician and went home with detailed instructions on how to adjust her insulin.

Another patient, Eric, said he left the hospital with a new diagnosis of COPD but no understanding of how and when to use his inhaler. He wished he had one-on-one time with his doctor in the hospital to learn more about the disease and how to care for it. The impersonal, uninformative discharge process frustrated Eric because he “had millions of questions.” Feeling uninformed, Eric said he was “really scared to go home… I didn’t know how it would turn out.”

After discharge, he continued to smoke. He lacked the energy to take care of himself and was back in the hospital within the month. Thankfully, the second time around, he was flagged by his health plan and received better follow-up care. He was referred to a smoking cessation program and was provided information about his COPD. He also was discharged with a small wireless monitor to help him track his breathing and flag any early signs of breathing problems.

Unfortunately, these stories are commonplace. While every patient’s case is unique, this report underscores that many are not receiving necessary information about how to take their medications, how to follow up their care and how to recognize potential complications once they leave the hospital.

Getting Everyone Involved In Preventing Readmissions

Everyone has a role to play in making the transition better. Patients need to be engaged in their care. They need to ask questions, bring a friend to take notes, or even record the discharge instructions on their cell phones. They should ask for a detailed discharge plan, and know what to do if they begin feeling sick again.

Hospitals and care managers can make a difference by providing information in a patient’s primary language.  They can contact patients’ primary care providers. They can make follow-up phone calls and visits, and they can connect patients with community resources to help with everything from getting groceries to getting transportation to the doctor.

Policymakers need to pay attention, too. Readmission of patients varies markedly in different regions and even from hospital to hospital. Policymakers should note this study finds that some communities rely on hospitals to be primary sites of care. This is vital to understand, because even though hospitals are places that save lives, we need to get people the care they need outside the hospital walls. To do that, policy and payment initiatives should encourage greater coordination between hospitals, primary care providers and community resources.

A Variety Of Tailored Solutions Rather Than A Single Magic Bullet

There isn’t a single solution to this problem. In fact, our discussions with physicians and nurses reinforced what we have learned through our other quality improvement initiatives, such as Aligning Forces for Quality: health care providers are finding many ways to tackle this issue — ways that work best for their patients’ individual circumstances.

One hospital established a 24-hour pharmacy right on site so patients can fill their prescriptions before they go home.  Another created a special clinic for heart failure patients who are particularly prone to repeated admissions. As a result, discharge planning and follow-up care are improving at both these sites.

We all need to care about this, not only because of the millions of dollars spent on needless readmissions, but also because improved transition care can save lives and improve the quality of life for our neighbors, our family members and our friends.

As the nation’s largest foundation dedicated to improving the health and health care for all Americans, we believe this report will help us all recognize the role we have to play in lowering unnecessary readmissions and moving our country toward better health.