Patient Readmissions: A Case Study

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

In 2011, there were approximately 3.3 million readmissions to hospitals, raising healthcare costs and negatively impacting patient health. Two important contributors are discharge planning and education. Many patients do not receive enough of either, and are sent home misinformed about their diagnosis and medications. In order to decrease readmissions, hospitals should utilize interactive patient systems to educate patients while they are in the hospital. This will increase patient knowledge of their diagnosis, as well as make it easier for nurses to go over discharge teachings with the patient. This gives

Ineffective discharge teaching often leads to unnecessary admissions to the hospital resulting in negative patient outcomes and decreased patient satisfaction. This negatively impacts the well-being of the patient and creates a financial burden on institutions. As a result, this universal practice issue requires a call to action on the part of the nursing profession. Nurses can proactively assist in assuring incidents of readmission do not occur. Nurses as educators play a critical role in the successful transition of patients from hospital to home. The overall goal of discharge education is to ensure there is an exchange of critical information between the patient and nurse in which plans of care are understood and followed. The research

The office would need to establish a goal to accommodate all post-discharge patients. When appointments cannot be made then an escalation process to the office manager needs to occur. In order to foster communication with professional partners, an investigation of the system failures. How can the transition to home be improved? The workflow should include a validation step that would entail hand-off communication between hospital rounders and office schedulers. If missteps occur, then the office staff could catch the near misses and call the patient at home. Care coordination among providers on an outpatient basis could be supported by the electronic medical record and having verbal care conferences. Next strategy could involve the hospital completing a call back within twenty-four hours to all patients discharged. This intervention could potentially catch some of the missed opportunities. Another approach involves face to face reinforcement of the patient-centered partnership with H. H. According to Counsil et al. (2012), “patient-centered care plans for complex patients changed the relationships with the health team” (p. 190). The development of this patient directed plan of care and partnership is

The Affordable Care Act was enacted to improve health care and to lower health care cost in America. The ACA developed different strategies to meet these goals called the “pay for performance” programs. These strategies are aimed at the different providers to improve quality care. The strategy that I selected is the “Hospital Readmissions Reduction Program” this program/strategy is also known as the HRRP and was begun in October of 2012. HRRP is aimed at hospitals and penalizes hospitals that have a high 30 day readmission rate. The penalties are assessed and based on a number of comparisons, those such as, performance, patient demographics, comorbidities and frailty.

Patients recognize discharge as a distinct episode in their care but, it also can skew their perceptions of the entire hospitalization. Educating, empowering and engaging the patient with pertinent information and support tools can make a vast difference in the success of their post-discharge care. The MDW is a low-cost tool designed to increase the patient’s knowledge and understanding about their medications upon discharge. Most hospitals have printed medication instructions in order to fulfill the “Meaningful Use Requirements,” that was initiated with the Medicare and Medicaid EHR Incentive Program. But, there is not standardization on how and when to use the MDW in the discharge process. The goal is to have better communication about medications. We are proposing that the MDW be incorporated into discharge teaching for all inpatients. This will require hospitals to reassess their current discharge processes and then, redesign the process to improve on what they have. The existing process will be redesigned to simplify and standardize the process throughout the organization. There will not be a need for additional personnel. The roles of

The teach-back method has been of great help in improving retention of new medication information, reducing medication errors and in closing information gaps among patients medication education (Kornburger et al., 2013). This method is really simple and straight forward where in the nurse starts by instructing the patient about the new medication followed by having the patient repeat the same information back to the nurse. This way, the nurse is provided by an opportunity to see what the patient has

Post-discharge follow-up visit remains a critical factor in ensuring that patients continue to do well after they leave the hospital. The success of the team was measured based on data collected after 6 months of revamping the discharge clinic and implementing a phone call system to patients. They had been given a choice of a phone call for discharge follow up or to come in within 7-14 days and be evaluated post discharge.

al, 2003). A systematic review of research consisting of effective discharge planning and how it affects hospital readmission rates was conducted. The review identified that effective discharge planning does have a direct correlation with the reduction of readmission rates. Patients that understand their diagnosis, medications and what to expect tend to have a better transition to home or nursing home. Also patients given support and information related to new medications and diagnosis are more successful at managing their health at home. Including the PCP is a great way to ensure the patient will have the necessary care and support to continue to succeed at home.

Are our patient’s culture, language barrier, education level, and poverty factors leading them into early hospital readmissions?

As an individual who cares about health, including the Aspen Idea Festival and formerly employed at Prevention, I would like you to consider this thought, the way patients our educated before a hospital discharge must be reconsidered.

Silverstein et al. in [24] were to develop and validate predictors of 30 day hospital readmission using a dataset of more than 29,000 patient’s record over the age of 65 and to compare prediction models that used alternate comorbidity classifications. In these paper they were capable to identify the risk factors of hospital readmission and calculated the risk of all the attributes by using prediction model. An important limitation of their study was that it did not directly include information on patients’ abilities to perform activities of daily living or other measures of physical function.

The key to decreasing readmissions, reducing risks, and improving the discharge planning process is through a good system design, which takes into consideration all the components to this complex issue. Therefore, in order to produce an effective intervention, hospital systems must fully comprehend the key concepts in general system theory; thereby, analyzing the involved systems so that the issues can be improved upon (O’Brien-Pallas, Meyer, Hayes, & Wang, 2011). Paying close attention to the arrangement of and connections among the parts in how they function collectively as a whole is the core of systems theory, which is also considered a holistic approach (Ansari, 2004). The way the parts are organized and how they interact with each

In order to improve patient education regarding their medication, a quality improvement project has been designed to educate nurses on techniques for effective communication. One evidenced-based process to improve medication education and communication is utilizing the teach-back method. This educational method has been shown to improve patient knowledge and retention of information (Nurit et al., 2009). The Joint Commission, American Medical Association, National Quality Forum, American Nursing Association, and the Health Literacy Collaborative have recommended implementing the teach-back method to provide effective communication to improve protection of patient safety (Iowa Health System, 2014). The teach-back method involves educating patients about a topic and having them repeat back in their own words what they understand about the topic. By using this method, the instructor can decipher the patients' understanding of the topic. If patients cannot repeat back the information or are incorrect in their answer, this then alerts the instructor that they require more information and education. The teach-back method has been found to improve patient outcomes and protect patient safety (Weiss, 2009).

The need to educate patients about the medications they are receiving is becoming more and more important. Patients may have no idea why they are taking the medication that they are prescribed. When patients know why they are taking a medication and what some of the side effects are to that medication they are able to keep themselves safe. Patient safety related to medication communication is something that may be overlooked in settings that prescribe medications. The more knowledgeable the patient is about the medications they are taking the better they are to understand their specific disease process and improve their own safety. “A patient’s understanding of his or her medications is vital to a satisfactory patient experience and it also drives safety and quality” (Improving Medication Communication with Ask 3/Teach 3, 2013).