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Prevent Readmissions With Nurse Intervention

Rebecca Hendren, for HealthLeaders Media, September 27, 2011

Changing reimbursement incentives are forcing hospitals to focus on preventing readmissions. Yet hospitals are stymied when patients fail to take their medications. Adding a home visit from a nurse soon after discharge may provide a beneficial and cost-effective option to keep the most complex patients out of the hospital.

Nurses routinely follow up with discharged patients by telephone to monitor their recovery and ask about medications, but that can be insufficient.

“We couldn’t tell on the telephone that they were not taking medications,” says Linda L. Costa, RN, nurse researcher at The Johns Hopkins Hospital, and assistant professor at Johns Hopkins University School of Nursing.

Increasing nurse involvement to include in-person follow-ups may help patients stay on track, according to a study by an interdisciplinary research team that included two nurses and a pharmacist based at The Johns Hopkins Hospital.

The study, funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative, followed a group of chronically ill patients taking multiple medications and examined whether a simple, early intervention could make a difference in the patients’ post-hospital progress and prevent readmissions. The study sent nurses on home visits to discuss medications and solve problems that prevented patients from sticking to their regimens.

Costa, the lead researcher, says the study’s genesis was calls from patients to nurses after discharge to clarify medication orders.

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3 comments on "Prevent Readmissions With Nurse Intervention"


Amy (12/11/2011 at 6:38 PM)
It's great to see this article. I've worked in both the hospital and home setting as a nurse for about 10 years now. I've seen first hand what can happen between the hospital discharge to home. It's been sometimes amazing what you might find once you go into a home. Medications is definitely a big one and many times is related more to understanding rather than financial. I've been fortunate to learn a lot from working in both areas and try to incorporate what I've learned in my everyday practice whether in the hospital or the home.

Matt (9/30/2011 at 11:06 AM)
Did the study have an ROI? Or was it just money spent to reduce readmissions? Is it feasible fiscally to have nurses that make home visits? APNs or RNs?

Naomi Ervin (9/30/2011 at 10:51 AM)
It is great to see that home health care nursing has been re-discovered. This type of nursing service has been available for over 100 year. Numerous studies have demonstrated the effectiveness for early discharge and preventing re-admissions.