Prevent Readmissions With Nurse Intervention

Rebecca Hendren, 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.

Rebecca Hendren Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at
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