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Ambulatory Interventions Needed to Prevent Readmissions

Analysis  |  By Kenneth Michek  
   July 19, 2018

To move the needle on readmissions, hospitals need assistance from non-acute care partners. Nurses can meet the need.

Hospitals are increasingly on the hook for 30-day readmissions, but a recent study published in the Annals of Internal Medicine indicates that some rehospitalizations during that timeframe would be better prevented by outpatient clinics and homecare.

"Our findings suggest that the 30 days following hospital discharge are not the same with regard to what influences outcomes for sick patients, and that the current model over-simplifies this high-risk time," says the study's co-author Kelly Graham, MD, MPH, director of ambulatory residency training at Beth Israel Deaconess Medical Center and an instructor in medicine at Harvard Medical School.

Related: Readmissions Are Down, Unless You Consider Rise in Observation Stays

The researchers found that readmissions within the first seven days after hospital discharge were more likely to be deemed preventable (36%) than those within eight to 30 days (23%). Hospitals were identified as better locations for preventing early readmissions, whereas outpatient clinics and homecare were better for preventing late readmissions.

"Patients discharged from a hospital are usually recovering from a serious medical condition as well as managing other chronic medical conditions, and they often encounter new logistical challenges adapting to this recovery period," Graham says. "Hospitals and outpatient clinics must work together more seamlessly to ensure that patients are equipped to manage these challenges at home."

Nurses Can Bridge the Gap

Since they can be found in all care settings, nurses are in a unique position to improve care transitions and reduce readmissions. Here are three HealthLeaders articles on how to accomplish those goals: 

  1. Solidify the Nurse Leader's Role in Care Coordination: Nurse leaders can use various strategies to improve care coordination and transition management including studying an organization's care transition model; clearly defining the key roles and responsibilities of care coordination; and engaging patients and families.  
  2. Hospital Cuts Readmissions in Half with Help from College Students: After one Ohio hospital trained liberal arts college students as community health workers, patients enrolled in the program had a 26% reduction of ED use and 51% reduction in hospital readmissions. The undergraduates received training as health coaches, and each student was assigned two patients to visit once a week. During the visit they helped patients set goals and reported any issues to the patients’ primary care provider.
  3. Adding this Step to Discharge Planning Slashes Hospital Readmissions by 25%:  A study published in the Journal of the American Geriatrics Society found that integrating informal, unpaid caregivers into discharge planning for elderly patients led to a 25% decrease in readmissions at 90 days. These caregivers were typically the patient's family members and by including them in the treatment plan better patient outcomes were achieved.

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