Decreasing Hospital Readmissions

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Decreasing Hospital Readmissions

How nurses have been pivotal in keeping patients healthy

By Elizabeth Hanink, RN, BSN, PHN
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Plenty of people don’t really want to hear more about health care reform. But there is one study that focuses on a problem that the nursing community knows exists — the high rate of hospital readmissions. In 2004, the New England Journal of Medicine revealed that unplanned readmissions cost Medicare $17.4 billion each year. One in five rehospitalizations occurred within 30 days of discharge, and by day 90 a full 34 percent of patients were back in acute care. Half had not seen a primary care physician since discharge.

A recent study released by the California HealthCare Foundation, “Homeward Bound: Nine Patient-Centered Programs Cut Readmission,” offers examples of community efforts (many California-based) that have reduced patient cycling in and out. What was the single most common denominator in all? Nurses, of course. They were the key, whether they worked as discharge advocates, home health nurses, case managers or simply called patients to check on progress.

No one should be surprised. Of the whole medical team, the nurse is the one most likely to perform the four activities that seem to prevent readmission: coordination of post-hospital care across settings, prompt medication reconciliation (what’s prescribed versus what is actually in the home), engagement of the patient/family in active participation (including recognition of red flags), and timely follow-up with the physician. No one cares like a nurse.

For the full study go to and search “homeward bound.”   

Elizabeth Hanink, RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.

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