Keeping patients with multiple chronic conditions out of the hospital has always been a challenge for healthcare providers, but an increasing awareness of why patients return combined with a push to reduce healthcare costs, has put hospital readmission rates under the national spotlight. A growing number of hospitals, home-health agencies and insurance companies are introducing pilot programs aimed at improving the transitions of patients discharged from a hospital to the community and hoping to reduce the number or patients returning. Almost all of these programs significantly involve nurses: as coaches, educators, care coordinators and patient advocates.
“Nurses play a central role in the prevention of hospital readmissions. This is well-documented in a number of studies,” says researcher Mary D. Naylor, RN, PhD, FAAN, professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University Of Pennsylvania School Of Nursing.
A recent study in the New England Journal of Medicine found that 20% of Medicare patients discharged from hospitals was readmitted within 30 days, and about one in three returned to the hospital within 90 days. The government spends an estimated $12 billion a year on “potentially preventable” readmissions for Medicare patients, according to the Medicare Payment Advisory Commission.
Naylor and her colleagues have developed a transitional-care model that uses advance practice nurses to follow high-risk elderly patients from the time they are admitted through the day they return home and the weeks beyond. Nurses visit patients in the hospital every day, make follow-up appointments and accompany patients to doctor visits to help them ask questions and understand answers. They teach patients to assess their own symptoms using a traffic light model, with green for feeling fine, yellow for a minor problem and red for symptoms so severe they should call 911 or go to the ER.
The nurses work with the patients for up to 12 weeks if necessary, though six weeks is sufficient for most. Naylor’s studies have shown an average savings of $5,000 per patient one year after hospitalization. Naylor’s model is one of the most intensive of readmission prevention projects.