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Hospital Readmissions: Transitions of care
As quoted from the agency of Healthcare Research and Quality:
“Reducing preventable hospital readmissions is a national priority for payers, providers, and policymakers seeking to improve health care and lower costs. In 2012, the Centers for Medicare & Medicaid Services began reducing Medicare payments for certain hospitals with excess 30-day readmissions for patients with several conditions.”
Here is a fact: Hospital staff, discharge planners and hospitalist among others, do a great job in discharging patients from the hospital. The fact is…they can only do so much! They only directly control the information they can give the patient. Other details or continued care has to be coordinated with other institutions such as rehab facilities or home health. Once the patient is discharged, even if those mentioned care options are utilized, should the patient return to the hospital and is admitted, the hospital remains accountable. These problems could result from:
Patient was discharged too early before adequately stable or without continued care in place (we all know this happens)
Discharge location cannot support the recovery
Exacerbations or worsening of the original disease because of a lack of patients understanding of their disease self-management, discharge instructions, non-compliance, inadequate caregiver support or lack of caregiver knowledge, lack of follow-up, medication errors at home or unidentified barriers that impede optimal recovery.
So…what’s the point? A post hospital hand-off to an RN for a one-on one relationship with the patient to usher them from the hospital to the physician recommended destination is an essential method to assure the patient not only has the support needed, but also is receiving education that extends to the caregivers. This is a transition of care episode with the ultimate goal not only to decrease the chances of a readmission but to:
Promote the efficacy of coordination of care
Ensure continuity of care
Ensure appropriate information is communicated to multiple providers for a safe transition