This is the second in a series of posts about readmissions.
As readmission rates continue to be a concern for hospitals looking to mitigate financial penalties from the Center for Medicare & Medicaid Services, programs that extend patient care beyond the four walls of the hospital are rising in popularity. Nurses are one of the care providers with the most hands-on access to patients. They can play a significant role in influencing patient behavior and ensuring a safe care environment—ultimately helping to reduce readmissions.
Rather than viewing the point of discharge as the end of a hospital’s role in the care process, facilities with these follow-up programs recognize the benefits that continued involvement in care have on their patients and the hospital. According to one report, nearly 1 in 5 Medicare patients return to the hospital within 30 days of discharge.[i] Optimizing transitions of care and counseling at the point of discharge can reduce these rates and be accomplished by better leveraging the clinical expertise of nursing.
The hospital’s role in reducing readmissions can begin before the patient leaves the hospital through structured and systematic discharge planning. By creating a routine, systematic approach, hospitals can help ensure a smooth transition back to the home or to a post-acute care facility. Incorporating this into the patient’s care plan allows nurses to set aside specific time to accomplish this task, as opposed to rushing through it or disrupting other necessary activities.
Many programs have also seen success by constantly reinforcing discharge messaging about medication management and proper follow-up care throughout the patient’s stay, rather than piling on information when individuals are headed home.
At the Boston University Medical Center, for example, Project Re-Engineered Discharge (RED) helps improve coordination by using nurses specially trained as discharge advocates to coordinate a patient’s care. This can include exchanging information with any post-discharge providers or family caregivers and offering problem-solving to patients through post-discharge phone programs.
Implementing a standardized universal checklist for discharge protocols can help ensure all patients receive the necessary level of discharge counseling and care. In Project BOOST (Better Outcomes for Older Adults through Safe Transitions), this list includes:
- General assessment preparedness
- Medication reconciliation
- Direct communication with any outpatient providers to ensure follow-up care is received
The BOOST program toolkit was developed by The Society of Hospital Medicine, and has been downloaded by more than 4,000 hospitals to date.
Post-Discharge Follow-up Care
Many hospitals have some type of post-discharge program in place, usually involving a follow-up phone call approximately 48 hours after discharge. However, the Joint Academy Program at CHI St. Vincent extends this service to offer pre-surgical and post-surgical calls at 24-hours, 48-hours, 10-days, 30-days, 90-days, and 120-days after discharge. By extending the duration of follow-up calls, nurses are able to catch more long-term symptoms or complications, such as bruising, which may not develop until seven to ten days after surgery.
In addition to personalized discharge programs, increasing nursing employee satisfaction can also positively affect readmission rates. Research shows that when nurses are happy with their jobs, they become more involved with and invested in patients, which results in better care. Additionally, when nurses have fewer administrative burdens placed on their time, they can spend more of their day at the patient bedside. This time can be valuable in forming a relationship with the patient, and planting the seeds for discharge recommendations.
While there are many indirect factors of readmission that cannot be addressed, such as lack of transportation or an inability to pay for prescriptions, increased nurse involvement can offer additional support to patients and help identify medical complications before readmission is necessary.
View the previous post on readmissions here.
[i] Shepperd S, et al. Discharge planning from hospital to home. Cochrane Database Syst Rev 2013;(1):CD000313.