The Movement Of Patient's Between Healthcare Settings And The Opportunity For Communication Breakdowns

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.

Readmissions is a basis for financial penalties to hospitals as a provision of the Affordable Care Act by reducing payments to hospitals with an” excess” 30-day readmissions. The data showed that patients living in high poverty neighborhoods were more likely to be readmitted, older and male patients were more likely to be readmitted as opposed to young and female patients. Lastly, patients with CHF, acute myocardial infarction, and those with certain diseases, such as diabetes, liver and kidney disease were at higher risk of being readmitted. The data also showed married patients were less likely to have a readmission because of more social support (Study Links Social, Community Factors with Hospital Readmissions,

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

In a world of budget cut and layoffs, medical corporations face new and different challenges in addition to helping and healing patients. I used to work as a medical biller in a physician’s office for five years and I experienced how difficult for the health care providers to get reimbursed. The government and the insurance companies have been limiting the budget towards the health care services. This action also affects the hospitals greatly because Centers for Medicare & Medicaid Services (CMS) and some policymakers have requested the hospitals to reduce the

State Action on Avoidable Readmissions (STAAR) – this is a pilot program to improve care transition that concentrates on developing community-based and state-based

The aim of the Affordable Care Act (ACA) is to reduce hospital readmission and to increase implementation of transitional care coordination for low health care cost. One benefit of establishing this

Partnership for Patients (PfP) has made significant progress in decreasing the number of preventable hospital acquired conditions (HACs), hospital readmissions, hospital patient deaths, and health care expenditures. Nonetheless, much work remains to be done so that PfP is more effective in their mission to make and improve care safety and care transitions. The progress made is part of a program that has been in effect since April of 2011, soon after sections 3011 and 3026 of the Patient Protection and Affordable Care Act (PPACA) were signed into law. These sections allowed then Department of Health and Human Services (DHHS) Secretary, Kathleen Sebelius, and Center for Medicaid and Medicare Services (CMS) Administrator, Donald Burwick, to create and provide funding through Medicare for a dual program to reduce hospital readmissions and transition care services.

With a variety of trends that account for the increasing cases of the elderly population at risk for hospital readmission, the authors discuss an in depth evaluation on why this occurs. Hospital readmission, a growing health concern, tallied in a whopping $17 B in Medicare cost for unplanned hospitalizations. Readmission, refers to a return to the hospital after discharge from a recent stay where rates are reported mostly at 30, 60, and 90-day intervals after discharge. Even though the elderly, aged 60 years or older, unfailingly represent the highest rate of hospital readmissions compared to other age groups, according to the authors, readmission rates have been associated with patient demographics, chronic conditions and utilization factors. Additionally, although the aforementioned factors contribute to readmission, adverse events such as injuries that result from hospitalization or at home like medication errors. According to (Robinson, Howie-Esquivel, & Vlahov)

In December 2015, The Joint Commission launched a campaign seeking to reduce readmissions by providing resources for both health care providers and patients to engage patients in the discharge planning process.1,2 According to voluntarily reported data collected by The Joint Commission between January 2014 and October 2015, the major contributors to 197 sentinel events were failures in patient communication, patient education, and patient rights.2 A review of communication during the hospital discharge process found that discharge summaries often lacked information on counseling, treatments, discharge medications, test results, and follow-up plans.3

For years, healthcare costs have continued to increase in the United States and policymakers are constantly trying to find ways to reduce spending. According to reports, in 2011, about $900 billion out of the $2.6 trillion annual health care spending was wasteful spending. In the following year, there was a reported $690 billion wasted annually on healthcare. This wasteful spending is attributed to ineffective health care delivery, cost of adverse events, and poor care coordination that has led to avoidable readmissions (Lallemand, 2012). In the United States, readmissions are the highest amongst patients with chronic diseases accounting for about 90% of avoidable readmissions in 30 days after discharge, and costing the industry an estimated $17 billion. These readmissions are a result of inadequate discharge planning, lack of follow-up, and lack of education on disease management (Jayakody et al., 2016). Policymakers on the federal and state level have developed and implemented several programs, some varying state to state, to help reduce wasteful spending while improving quality of care.

Finding ways to decrease readmission for patient with a chronic disease process has brought about change with the use of technology. As of October 2012 hospital are penalized 1% from Medicare for every patient who have excessive readmission for certain chronic disease such as pneumonia, acute myocardial infarct (AMI), and chronic heart failure (CHF) in addition to the amount increase by 1% for the following two years (ACEP, n.d.). Engaging and monitoring patients with chronic disease outside the hospital include supplying a patient with CHF with an I Pad, blood pressure monitor, digital scale, pulse oximetry, and hand held heart monitor provides data. The patient checks in daily from home and the data is analyzed to determine if any intervention

I work as a case manager as well. My former work as an RN case manager is in a medical group and my current setting is also in a medical group but I am now assigned in one of the hospitals, here in Southbay California. Great post regarding the transition of care. You are also correct, that CHF is one of the leading cause of patient re hospitalization, which is followed by Pneumonia and MI. Unfortunately, high readmission rate is a current issue that needs to be addressed, and that is also why Medicare will reduce payment to hospitals with excess readmission rates. (Kripalani S., Theobald, C., Anctil, B., & Vasilevskis, E. 2014). Although, this is a great effort, we can still see patients going back to the hospital within the 30 days. Studies

There are multiple questions that can be drawn from this case study; chronic obstructive pulmonary disease (COPD) clients, will always have multiple readmissions as oppose to other patients with diagnosis. “If all readmissions were counted regardless of diagnosis, one out of five index admissions for COPD (20.5 percent) were followed by a readmission within 30 days (Elixhauser, Au, and Podulka, 2011). Mary’s history of diabetes; the sole care taker of her ailing husband and an untimely recommendation of transitioning to a skilled facility, put her at risk for some kind of psychosocial issue, for example depression. Also, her days are stressful, and she has no family support. Care givers do need to take a break periodically, or they will

Cost is always a great way to persuade stakeholders, and some of the literature discusses the financial impact of readmission. It was found in one study that due to the intervention of follow-up phone calls, the cost savings of readmissions within thirty days was reduced by $1.4 million dollars (Harrison, Hara, Pop, Young, & Rula, 2011). In the new nursing culture, it is important to offer patient-centered care, and the intervention of discharge phone calls does just that. Each article discusses the quality of effective communication and how this improves patient satisfaction surveys and overall

Study Name: The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review