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Prevent Readmissions With Nurse Intervention

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   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.

Many patients with chronic illnesses face complicated medication regimens they may not understand, have prescriptions that need to be filled, or wonder what to do about prescriptions they had been taking before hospitalization.

“We had to go to the home and see it,” Costa says. “It was the only reliable way to really know what [their] medication management is.”

In the home visits, the nurses could determine patients’ understanding about managing their medications. Nurses called the patients two days after discharge to talk about their medications, then visited patients’ homes two weeks after they had left the hospital.

The home visit “was really the way we could see what was going on, as far as medication went,” says Costa. “We could look at the bottles, see how they organized medications [and] filled prescriptions, if they understood what medications they were supposed to be taking.”

The nurses identified discrepancies between treatment plans and what patients were doing post-discharge. “Many discrepancies were not intentional,” says Costa. “Patients were just confused with the instructions.”

Study participants were taking about 10 medications on average, so instructions were plentiful and complicated. The nurses were surprised to learn that money was usually not the barrier to medication adherence. “A lot of patients did have supplemental help because they were lower-income,” Costa says. “The problems were mostly in not understanding or deciding not to take a medication.”

The nurses found that talking with patients and their families improved their understanding of their medication regimen and increased compliance. But the nurses struggled with patients discontinuing medications because of side effects.

The study “confirmed that if they felt a med was not helping them or made them feel worse, they stopped taking it,” Costa says. “How they identified which medication was random. It could be a blood pressure pill or a blood thinner pill. They would select one or two and they would stop taking them if they felt it was affecting them. It wasn’t related to particular side effects and it was pretty random as to which one they didn’t take.”

In some cases, the most important nurse intervention was counseling patients to tell their doctors that they were not taking or had problems with particular medications.

Costa ran the pilot study on a small budget and hopes to examine the larger implications of the findings with further research. She says the initial results indicate that home visits provide a good return on investment.

“If you look at the costs that hospitals will spend to reduce readmissions, the cost of this program is not that significant,” she says. “We’re seeing patients in our local area, so it’s feasible to do. There is value to be had and I don’t think it’s exceedingly costly.” 

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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