Readmissions In Healthcare

In today’s healthcare setting there is a false belief that care for the patient ends once discharge occurs. From the moment the client is admitted into the healthcare facility our main focus as a unit is to make sure that the patient is alleviated of their acute episode of illness and discharged back home. As healthcare providers it is our responsibility to ensure that the patient has the smoothest transition from hospital to home also known as transitional care. According to the American Geriatrics Society (2003) transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. The transitional

According to the Centers for Medicare and Medicaid Services (2012) readmission is defined as an admission into the hospital within 30 days of a discharge from the same hospital or another sub-section hospital. Reducing the rates of unnecessary readmission into acute care facilities has now become the focus on healthcare quality improvement efforts through the use of the transitional care model. Readmissions are expensive. In 2011, the Healthcare Cost and Utilization Project estimated that 30-day adult all-cause hospital readmissions were associated with around $41.3 billion in hospital costs (2011). To reduce the relatively high rates of readmissions, especially for Medicaid/Medicare patients who encompass a total estimate of 130 million beneficiaries (CMS 2017), the Affordable Care Act implemented the Hospital Readmission Reduction Program abbreviated as HRRP, which financially penalizes hospitals with relatively high rates of Medicare readmissions. (CMS 2017). According to Kaiser Health News, in 2016 more than half of U.S. hospitals were penalized by the Centers for Medicare & Medicaid Services for their readmission

The change revolves all around discharge and follow-up appointments. Discharge is the first intervention that should be improved to ensure quality transitional care. It is the golden rule that is taught to all nurses that discharge begins upon admission. I’ve had a firsthand witness of multiple discharges within the hospital and can truly say that a majority of the patients were not receptive to the teaching. It is understandable why discharge teaching would go into one ear and out the other. The patients are ready to leave the facility and therefore can only grasps a handful of what is being taught to them in those crucial moments between leaving the facility to go back to a home setting. In that small window of time it is not effective to teach about medications or conditions, gain necessary information about patient home life and prepare the patient for the next care setting. Discharge instructions should be patient-centered, individualized and an interdisciplinary approach that occurs throughout the length of the hospital stay and is not concentrated at the end of it, commonly known as peri-discharge. Follow ups with patients, either over the phone or in person, are an underutilized portion of the transitional care model. In a clinical trial study by the Department of Cardiology Medicine at the Boston University Medical Center, the approach of an