An Individualized Plan to Reduce Readmission

Failure To Communicate: Why Seniors Are Readmitted To The Hospital So Often

This article  in Forbes highlights the importance of continued care after the patient leaves the hospital as a key to reducing readmission. It provides some important qualitative data about readmission issues from the patients' perspective. Here's my take on this, based on my nursing experiences providing care in hospital, clinic and home settings, as well as being on the patient and family side of the issue with several family members.  Continuity of care is important, but some keys will be important to ensure that it is effective.

Care after discharge should  should happen IN THE HOME with the caregiver(s) and others who are involved in the patient's life. In the home, ON THE PATIENT's OWN TURF,  the patient is comfortable and in control- key elements that are missing in the hospital or clinic. In the home the provider can most effectively develop a good understanding of the patient's resources and environment, how s/he lives, their responsibilities, and what is most important to that person. These are all keys to working with the patient to develop a self-management and follow-up plan. The plan needs to be realistic yet as simple as possible, targeting the few self management interventions that the person should focus on doing consistently, and that will be most important to reducing readmission for that particular person- their low-hanging fruit. The motivation for following this plan should focus on the things that determine that person's quality of life- showing how this plan will help them live as they want to- that will make it meaningful and will help motivate them.

Research has shown that reduction of readmission rates for older adults with heart failure CAN be achieved through comprehensive discharge planning followed by post-discharge care. This should include a home visit by a nurse and/or clinical pharmacist for anyone at risk of readmission during the first few days after discharge. This visit should include a comprehensive assessment, documenting key information about resources, environment, support systems, barriers, etc in the EMR where it is AVAILABLE TO ALL PROVIDERS. This visit should include the development of an individualized plan for self management that focuses on a FEW KEY SELF MANAGEMENT strategies that particular person needs to do to keep them out of the hospital- the low-hanging fruit. Finally, the person should be given ONE NUMBER they can call for any questions or concerns.

It's impossible to develop this kind of individualized, realistic self-management plan in the hospital during a crisis without the benefit of the person's support systems and without seeing how the person lives. That's one of the many reasons that discharge plan developed in the hospital alone and that do not provide continued care after the hospital are not going to be effective. And while clinic visits can be helpful, they  remove the patient from the context of his/her life without accurately reflecting their barriers and resources to self-management. Often, the clinic follow-up visits are scheduled 1-2 weeks after discharge- after the vulnerable period of transition from hospital to home is over, and they have already been readmitted. Therefore, a home visit during the 1-3 days after discharge will be most effective.

Another key to reducing readmission is communication. All who care for the patient where ever they go should have access to the plan through a computerized system that communicates across settings and organizations anywhere the patient goes. The person who needs the plan most is the patient, but and all of  those who are important in their lives need it too. It also needs to be documented where all of their providers can access it at a moment's notice, such as when the person calls in the middle of the night with a concern, or they present to the ED in crisis. And it should evolve with the person's changing needs, preferences and resources.

Keys to an effective plan for reducing discharge from the perspective of the patient and family? Simplicity. Effectiveness. Individualization. Continuity.  So how can we ensure that this consistently happens in EVERY HOSPITAL for EVERY PATIENT at risk of readmission?