Translation Science Project-Hospital Readmissions

No patient wishes to return to the hospital after discharge as readmission often disrupts an individual’s health. Rehospitalization is also costly and affects the patient’s everyday life. Readmission is usually caused by non-compliance in treatment, inadequate care transition, misinterpretation of discharge instructions, complications with health conditions, demographic factors, and more. Research shows that healthcare facilities can reduce readmission cases by 30% if they understand its root cause and applying more targeted comprehensive care. Patients receive such care from post-acute care centers, where they get support for their recovery from capable specialists under an inpatient rehab program.

About 1.5 million individuals in the US receive care from more than 17 000 skilled nursing personnel annually. Registered Nurses (RNs) provide post-acute care (PAC) through rehabilitation programs while assisted by ADLs and IADLs. Doctor of Nursing Practice scholars (DNPs) also reduces readmissions by developing evidence-based programs to improve PAC (Thomas et al., 2018). While most patients receive these rehab services at PAC centers, some get the services in their primary residence. Readmission or rehospitalization is a significant challenge to patients and facilities, often leading to adverse health outcomes. Other common issues associated with rehospitalization following discharge from post-acute care centers include cognitive impairments, decreased appetite, increased falls, sepsis, and more. With an effective PAC program, care providers can ultimately reduce readmissions and improve healthcare and patient outcome.

Practice Problem and Question

Discharge from acute care settings to skilled nursing facilities has about an 18% readmission rate compared to about 16% of home discharges. The US records about 40 million discharges and approximately 20 billion dollars unplanned readmission annually (UpToDate, 2019). These numbers prove the need to prevent readmissions from improving patient’s quality of life and wellbeing, and overall health. About 21.5% of Medicare patients were readmitted within 30 days of discharge in 2003; the percentage dropped to 20% by 2007 (UpToDate, 2019). Although there has been a notable decrease in the readmission rate since 2003, more needs to be done to reduce the problem by a significant margin. Medicare and other insurance companies continue to allocate financial penalties to PAC settings related to patient’s quality of life and care, meaning the facilities need to develop new guidelines to improve patient outcomes. Clinical research evidence can help identify the readmission rates and their impact on patient outcomes, apply evidence-based practice to overcome this challenge.

How can care providers reduce the readmission rate over eight weeks through regular patient round-up and oversight? According to the current CMS guidelines, a patient should encounter a care provider in a PAC setting once every 30 days. Clinical providers round up patients daily and sometimes by multiple specialists in an acute care setting to assess them fully and identify issues before they worsen. When care providers hastily discharge sub-acute patients to see them once every 30 days, patients often disappear, only to be determined when the condition becomes chronic. Subsequently, patients are sent to the emergency department and then readmitted. In severe cases, the outcomes are fatal, usually affecting the patient’s overall recovery or resumption to prehospitalization state. What difference can clinicians make if they round up the patients several times weekly to identify the issue and intervene early to avoid rehospitalization?

Evidence Synthesis of Literature to Address the Selected Practice Problem

Several articles are used to provide evidence addressing the impacts of readmission rates on patients and the necessary measures to combat the challenge. Agarwal et al. 2018 show care provider impact on patient outcomes and Medicare spending through Accountable Care Organizations. The study comprises 49 skilled nurses, 182 hospitals, and 55 home health care agencies to determine the impact of care provider participation in Account Care Organization on rehospitalization, patient outcomes, and Medicare expenditure. There was a decreased readmission rate at -1.7% for patients discharged from care providers participating in Accountable Care Organization. The Medicare expenditure and length of stay were also reduced by $940 and 3.1 days, respectively. The study concludes by advocating for the ACO payment model.

Dadosky et al. 2018 show the impact of the tele-management of heart failure patients discharged from PAC centers and the subsequent home reduced readmission risk. Precisely, the study analyzes the application of tele-management in patients with heart failure after discharge. The results included a 29% decrease in readmission rate in patients with a median age. Patients aged 81 years and above had a risk reduction of 6.51% compared to the control group at 27.25%. These results were significant, considering the patient population. The only drawback identified was the increased cost of tele-management and the accompanying personnel. However, the cost could not compare to the high reduction in readmission rate in the PAC setting; thus, the clinical outcomes were hopeful.

March & Mennella 2018 researched quality improvement to reduce readmission rates and improve patient outcomes in PAC settings. According to the researchers, poor working conditions and a high nursing-to-patient ratio are the primary causes of poor quality of care in a PAC setting. The further consequence is increased readmission rates due to poor patient outcomes in the initial treatment. March & Mennella advocate for lobbying for better working conditions, providing more support for nursing staff, decreasing patient nurse’s ratio, and appreciating state and federal regulations to reduce readmission rates, increase the quality of care provided, and improve patient outcomes.

Hatipohlu et al. 2018 research a 30-day All-Cause readmission Risk for Subjects with Pneumonia at the Point of care. The study used 650 patients in Cleveland Clinic Main Campus to determine readmission risk 30 days after discharge. Three hundred thirty patients out of the total subjects got readmitted to the health care facility within 30 days after discharge from a PAC center. According to the researchers, the readmission rate could be reduced by improving inpatient care, optimizing transition to PAC settings, and appropriate discharge planning and education. The research provided a well-reported readmission rate risk predictor related to the pneumonia model with sizeable discriminative capabilities, used in discharge planning to reduce readmission rates in PAC settings.

The articles address diverse challenges faced by care providers in PAC settings, leading to increased readmission rates and compromised patient outcomes. Challenges such as nursing shortage, dissatisfaction, and inadequate care plans have persisted in the healthcare industry for decades. However, the articles address common ways to overcome the challenges, including improving the quality of care provided, planning discharge comprehensively, and monitoring patients frequently to enhance the quality of their lives.

Appraisal of the Evidence to Address the Selected Practice Problem

The sources provide level III evidence quality; They suitably apply clinical practice and generalizability. Undoubtedly, all sources have limitations, but they provide enormous knowledge applicable to clinical practice for further research or clinical setting to improve patient outcomes. Besides, the studies follow suitable methodologies and consider practical subjects, providing better results. More importantly, the findings not only apply to PAC settings but the overall healthcare industry.

Translation Path

Developing a program is easy but no so with implementation. Health organizations usually face internal and external factors that complicate the implementation process, including financial limitations, strict regulatory guidelines, high patient-to-nurse ratio, and lack of support for nursing facilities. Overcoming these challenges demands a multidisciplinary approach consisting of nurses, therapists, pharmacists, social services, and providers to work cohesively to ensure the comprehensive quality of care provided to all persons. The same approach works excellently in reducing readmission rates and improving patient outcomes.

Lewin’s change model best applies in this case. In unfreezing, the first stage of Lewin’s Model, the organization determines potential changes within, assigns a support team, mobilizes people for change, and reviews shareholders’ concerns on change implementation. The second stage involves applying the intervention, which is generally shifting the organization’s culture. During this stage, the management considers the shareholders’ and workers’ views and addresses them accordingly to prevent failure or sabotage change due to potential resistance. In the final stage -refreezing, the management focuses on stabilizing or supporting the change as the new way of life and working collaboratively with shareholders and workers to avoid any regression (Morrison & Harms, 2018).

The proposed plan is to see patients at least three times a week while educating nurses on handling multiple patients. The facility will also develop huddles to promote comprehensive care coordination, identify potential decompensation, and intervene early to reduce readmission for patients. The DNP ensures continued support to sustain this strategy and influence the management to promote a culture for welcoming change with minimal or zero resistance (Harris et al., 2018). The DNP also develops a comprehensive care provision plan as the facility’s blueprint for improving care provision, referencing rehabilitative services, and discharging patients. The program will reduce readmission rates by 63% as anticipated when implemented effectively.

Conclusion

Post-acute care (PAC) centers are prone to high readmission rates due to compromised care provision, leading to patient decompensation. Readmission rates mainly emerge from the usual challenges encountered in health facilities, including nursing shortage, dissatisfaction, low salary, and more. The PAC landscape, usually predominated by inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home healthcare (HHC) providers, is changing rapidly. PAC utilization is also rising as hospitalizations shorten, leading to increased costs. Nevertheless, PACs have high readmission rates and report poor quality of care to patients and the community. PAC settings can leverage emerging leverage to improve through better transitional care processes substantially. Frequent clinician rounding and encounters are practical measures to identify problems and intervene early to prevent adverse patient outcomes. The measures will subsequently reduce readmission rates and improve patient’s quality of life and wellbeing, and overall healthcare. The above research evidence provides substantial data directing to diverse approaches for reducing readmission rates in PAC centers. However, a DNP must partner with nursing staff and the management to implement the plan effectively and achieve the set goal; Lewin’s Model of change suits this transitional process to minimize resistance to change by the organization members.

References

Agarwal, D., & Werner, R. M. (2018). Effect of hospital and post‐acute care provider participation in accountable care organizations on patient outcomes and Medicare spending. Health Services Research, 53(6), 5035–5056. https://doi.org/10.1111/1475-6773.13023

Dadosky, A., Overbeck, H., Barbetta, L., Bertke, K., Corl, M., Daly, K., Hiles, N., Rector, N., Chung, E., & Menon, S. (2018). Telemanagement of heart failure patients across the post-acute care continuum. Telemedicine and e-Health, 24(5), 360–366. https://doi.org/10.1089/tmj.2017.0058

Harris, C., Allen, K., Ramsey, W., King, R., & Green, S. (2018). Sustainability in health care by allocating resources effectively (SHARE) 11: Reporting outcomes of an evidence-driven approach to disinvestment in a local healthcare setting. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3172-0

Hatipoğlu, U., Wells, B. J., Chagin, K., Joshi, D., Milinovich, A., & Rothberg, M. B. (2017). Predicting 30-Day all-cause readmission risk for subjects admitted with pneumonia at the point of care. Respiratory Care, 63(1), 43–49. https://doi.org/10.4187/respcare.05719

March, P. P., & Mennella, H. D. A.-B. (2018). Quality Improvement in Long-Term
Care. CINAHL Nursing Guide. https://searchebscohostcom.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=nup&AN=T904176&site=eds-live&scope=site

Morrison, J. Q., & Harms, A. L. (2018). Case studies using program evaluation to drive evidence-based practices. Advancing Evidence-Based Practice Through Program Evaluation, 109–131. https://doi.org/10.1093/med-psych/9780190609108.003.0006

Thomas, L., McBride, S., Decker, S., Pierce, M., & Tietze, M. (2018). Developing competencies in nursing for an electronic age of healthcare. Nursing Informatics for the Advanced Practice Nurse. https://doi.org/10.1891/9780826140555.0024

UpToDate, 2019. Hospital discharge and readmission. Retrieved from
https://www.uptodate.com/contents/hospital-discharge-and-readmission