Unnecessary hospital readmissions occur for various reasons, including incomplete discharge planning, a lack of follow-up from the hospital, patients' difficulty in adhering to medication regimens and patients' inability to visit a provider for follow-up. However, one factor underlies all these reasons: communication. Poor communication with patients, family members and post-acute care facilities at discharge can result in confusion around follow-up care and medications. By educating patients at discharge and giving clear, specific discharge instructions to post-acute care providers, hospitals can help reduce readmissions, according to Patricia Button, EdD, RN, chief nursing officer and director of nursing content for Zynx Health.
For patients returning home after the hospital, providers need to educate patients on how to take care of themselves post-discharge. One of the most common reasons for readmissions is related to medication mismanagement, which often occurs because patients do not fully understand which medications to take when. Educating patients on their medications and ensuring they fill their prescriptions can prevent readmissions. This education often includes exploring if patients have adequate resources such as transportation to get their medications.
Other areas of education relevant to self-management include diet and exercise. For example, cardiac patients typically have a restricted salt diet and a low cholesterol diet, according to Dr. Button. Teaching these patients to weigh themselves regularly is a straightforward way to assess both diet and exercise compliance, as well as overall cardiac status. Reporting sudden increases in weight — that may indicate an excess of fluids in the body — can help prevent readmissions, she says.
Furthermore, hospitals' communication with patients should not end at discharge. Hospitals should confirm the patient has a primary care physician who will manage the patient's health post-discharge. Hospitals should then follow-up with patients by phone, electronically or in-person to ensure the patient scheduled or had an appointment with this physician.
Individualized care plans
For discharge instructions to be truly useful for patients, they should be tailored to meet the needs of each individual patient, according to Dr. Button. "A key factor in self-management is in the inpatient setting, really learning about the patient and exploring with [the patient] what will help [him or her] take the correct medications at the right time," she says. For example, for some patients, having a spreadsheet to write down their weight over time can help them remember to weigh themselves. For other patients, they may prefer to have a family member remind them, Dr. Button says. Identifying specific actions that will help patients manage their health after discharge will increase the likelihood of self-management success and readmission prevention.
An important piece of information to share with post-acute care providers is patients' recent readmissions, when applicable. For example, if a heart failure patient was readmitted four times previously in the same year, the discharge summary should include the factors associated with the readmissions so the hospital and post-acute care providers can develop a plan to address those factors, Dr. Button says.
Discharge summaries and care plans should also be specific. In the example above, if the patient was readmitted five times because he or she does not have access to transportation to fill prescriptions, the care plan should include arrangements for transportation or a visiting nurse so the patient can take his or her medication as prescribed, according to Dr. Button.
While hospitals need to communicate with the post-discharge caregivers of all patients, communication is particularly important for patients who are discharged to a post-acute care provider such as a skilled nursing or rehabilitation facility, because patients will need to be monitored on an ongoing basis over time. "It's very important that there is ongoing communication with caregivers at the skilled nursing facility who will be doing that monitoring and management of medication," Dr. Button says. "[Make] sure the staff at the skilled nursing facility are well educated about the care that needs to be provided, and if signs or symptoms indicate the patient is deteriorating, [they intervene] quickly to avoid readmission."
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Communicating with patients: The need for self-management
For patients returning home after the hospital, providers need to educate patients on how to take care of themselves post-discharge. One of the most common reasons for readmissions is related to medication mismanagement, which often occurs because patients do not fully understand which medications to take when. Educating patients on their medications and ensuring they fill their prescriptions can prevent readmissions. This education often includes exploring if patients have adequate resources such as transportation to get their medications.Other areas of education relevant to self-management include diet and exercise. For example, cardiac patients typically have a restricted salt diet and a low cholesterol diet, according to Dr. Button. Teaching these patients to weigh themselves regularly is a straightforward way to assess both diet and exercise compliance, as well as overall cardiac status. Reporting sudden increases in weight — that may indicate an excess of fluids in the body — can help prevent readmissions, she says.
Furthermore, hospitals' communication with patients should not end at discharge. Hospitals should confirm the patient has a primary care physician who will manage the patient's health post-discharge. Hospitals should then follow-up with patients by phone, electronically or in-person to ensure the patient scheduled or had an appointment with this physician.
Individualized care plans
For discharge instructions to be truly useful for patients, they should be tailored to meet the needs of each individual patient, according to Dr. Button. "A key factor in self-management is in the inpatient setting, really learning about the patient and exploring with [the patient] what will help [him or her] take the correct medications at the right time," she says. For example, for some patients, having a spreadsheet to write down their weight over time can help them remember to weigh themselves. For other patients, they may prefer to have a family member remind them, Dr. Button says. Identifying specific actions that will help patients manage their health after discharge will increase the likelihood of self-management success and readmission prevention.
Communicating with post-acute care providers: Sharing information
As patients transition out of the hospital, it is critical for the hospital to share information with the post-acute care provider and primary care physician to coordinate patients' care. Hospitals should send a discharge summary with the reason for patients' admission, their health status and medications prescribed to the primary care physicians or other providers who will manage patients' health post-discharge. Sharing this information can ensure all providers understand and adhere to the patients' post-discharge care plan, which can prevent readmissions.An important piece of information to share with post-acute care providers is patients' recent readmissions, when applicable. For example, if a heart failure patient was readmitted four times previously in the same year, the discharge summary should include the factors associated with the readmissions so the hospital and post-acute care providers can develop a plan to address those factors, Dr. Button says.
Discharge summaries and care plans should also be specific. In the example above, if the patient was readmitted five times because he or she does not have access to transportation to fill prescriptions, the care plan should include arrangements for transportation or a visiting nurse so the patient can take his or her medication as prescribed, according to Dr. Button.
While hospitals need to communicate with the post-discharge caregivers of all patients, communication is particularly important for patients who are discharged to a post-acute care provider such as a skilled nursing or rehabilitation facility, because patients will need to be monitored on an ongoing basis over time. "It's very important that there is ongoing communication with caregivers at the skilled nursing facility who will be doing that monitoring and management of medication," Dr. Button says. "[Make] sure the staff at the skilled nursing facility are well educated about the care that needs to be provided, and if signs or symptoms indicate the patient is deteriorating, [they intervene] quickly to avoid readmission."
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