What Nurses Can Do to Reduce Hospital Readmissions


preventing hospital readmissions

By Alana Luna, Contributor

Climbing hospital readmission rates can quickly drain a facility of its most important resources. From financial strain and added stress for healthcare workers to patients who get stuck in a revolving door in their quest to heal, the many issues linked to unnecessary hospital readmission are so notable they’ve caught the attention of the United States government. 

The Hospital Readmissions Reductions Program (HRRP) penalizes hospitals with too many readmissions, but nurses can help keep numbers in acceptable ranges by committing to the expert tips below.

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Use the first point of contact to reconsider all initial patient admissions

Readmissions won’t be in issue if patients who don’t require high-level hospital care are immediately redirected to outlets better suited to their needs —outlets that likely cost less money and get patients home sooner, too.

Meghan Nechrebecki, founder and CEO of Health Care Transformation, helps individuals and healthcare professionals achieve their goal of optimal health at affordable prices. “Oftentimes patients maybe having symptomatic issues that if brought to the awareness of a phone triage or outpatient clinic nurse, the issue could be addressed and properly routed to the right setting, whether that is a clinic or other urgent care setting rather than the emergency room.”

Rather than viewing ER triage as the first opportunity to diagnose a patient, train call-line nurses and clinic workers to gauge who might be better off in another environment, saving beds for patients who need them the most.

Facilitate a smooth transition to home care

Healing is rarely finished when a patient leaves the hospital. For nurses interested in reducing hospital readmissions, forging a long-term relationship with a reliable, knowledgeable home health care worker can be a key part of keeping patients on the right track after release.“Working alongside a discharge planner, nurses should have their favorite home care provider come into the patient’s hospital room as soon as possible,” says Ryan Miner of BlueStar SeniorTech. Providing patients with assistance finding qualified caregivers makes it less likely they’ll fall through the cracks or experience significant delays in care once they settle in at home.

Meghan Nechrebecki agrees, “When a patient is getting discharged from the hospital, the nurses in addition to the rest of the inpatient care management team play a vital role in making sure everything clinically, socially and financially is buttoned up for the patient.” Due diligence early on in the process can prevent poor outcomes later on.

Consider the patients’ needs and concerns

There is no such thing as an effective one-size-fits-all discharge plan. Every patient has unique needs and circumstances that require personalized attention. Some may not have support systems at home while others may have a dedicated spouse but mobility issues that make their two-story house a serious challenge. Unless those points of concern are identified and managed as part of an organized hospital readmissions reduction program, bounce back will continue to happen.

Amer Nabil is a psychiatric nurse practitioner who works at an inpatient hospital in Connecticut and with private clients through his site, Half Full Psychiatry. “Listen to your patients, ask them what they will find helpful post discharge and do not impose a discharge plan or follow-up on the patients,” recommends Nabil. "Otherwise, experience tells us that most patients will return to the ER.”

In her position as a risk management and patient safety professional at Saxton & Stump, Judi Olnick has seen the important roles patient engagement and effective communication play in getting patients to become active members of their healthcare team.

“Listening to the patient when they allude to a roadblock preventing their following instructions or complying with recommendations, asking open-ended questions to learn more about the potential barrier and working with the patient to remove, or work around, the barrier” are all ways Olnick feels nurses can provide patients the tools they need to positively impact their well-being.

Have a strategy for “frequent fliers”

Nabil brings up another interesting point in his discussion of patients who view the hospital as a place to malinger. These patients take up beds and other resources, taxing staff and diverting attention from patients with legitimate illnesses or injuries. To break the cycle of malingerers who repeatedly seek hospital readmission, Nabil recommends creating a strict discharge policy with the help of the ER crisis team.

For patients who wind up in a hospital’s behavioral health unit repeatedly, Nabil suggests the following: “[The] unit program should be strictly be followed, which may include attending groups throughout the day, eating meals in the hospital dining room and actively working on their discharge plan. This will prevent malingering clients from returning to the hospital for free meals and a place to sleep.”

Focus on clinical skills and communication to prevent hospital readmission

Nurses are often the primary point of contact for hospital patients. How we interact with our charges and supervising physicians could mean the difference between detecting a change in status or missing something crucial during an assessment. In those cases, physicians could order a patient to be discharged before that patient is actually ready to go home.

Debi Damas, an RN and group product manager for long-term post-acute care at Relias, emphasizes that the key to preventing unnecessary readmissions lies in nurses with sharp clinical skills. “Continuing education, focused on reducing knowledge gaps, is a fundamental way in which nurses can help reduce readmissions.”

Whether you’re a nurse working to improve your own skills or someone in management tasked with devising ways to reduce hospital readmissions, incorporating these smart tips is an excellent first step toward a more effective and efficient system.

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