Strategies for Hospital Readmission Reduction

The Hospital Readmission Reduction Program (HRRP) was established in the Affordable Care Act (ACA) to provide an incentive for hospitals to lower readmission rates. Reducing readmissions is a shared responsibility and Long Term Care facilities (LTCF) must do their share to ensure the success of the program.

The LTCF should have a procedure in place to identify the HRRP diagnoses and should establish monitoring parameters for these residents when they are admitted. They should also identify the hospitals that most frequently transfer residents to the facility and build a rapport with them. Residents should have frequent assessments for serious risks, such as falls.

According to the available literature many hospital readmissions are considered to be preventable, avoidable and unnecessary. Many factors and incentives influence the decision to send the resident to the hospital and the risk factors must certainly be considered.

Without doubt, there are times when the resident must be hospitalized without delay and as nurses we must be well aware of these situations. We must always perform our duties to the patients morally and legally.

However, it is important that nursing staff realise the very negative effect frequent transfers have on residents. They are transported from a safe and friendly environment by strangers to an unknown destination. Most often they are unaccompanied, as family members, if available, frequently agree to meet them at the hospital emergency department. Frequent transfers from Long Term Care (LTC) facilities to hospitals and returns increase the risks of residents acquiring or transmitting healthcare associated infections (HAI). One certainly cannot overlook the tremendous cost factor involved in these resident transfers.

Solutions to prevent readmissions to hospitals should include assessments, planning and communication.

Knowing the resident and using good assessment skills to prevent changes in condition becoming too severe. Some conditions can be managed in the LTC facility when it is feasible and safe advanced care planning can identify incurable diagnosis, and use palliative care options when appropriate.

Open and honest communication with family members, informing them of the resident’s condition can alleviate  their request for hospital transfers when change occurs, also reassuring them that appropriate care can be provided in the LTC facility.

Communication between the LTC facility and the hospital needs improvement. Poor communication at discharge can lead to inadequate follow up care by the LTC providers.  Identifying readmission risks and communicating these to the LTC facility staff to enable them actively manage these risks would be very beneficial.  The use of electronic messaging and records will help the hospital and LTC facility coordinate care.

Preventing care gaps by the discharge physician providing prescriptions for ongoing medications would greatly reduce  time wasted in contacting the LTC physician to initiate these orders. Arranging with the pharmacy for timely delivery of medication would also eliminate delays in administering prescribed medication.

The Centers for Medicare and Medicaid Services (CMS) has provided  “Interventions to reduce Acute Care transfers”  (INTERACT).  This is a quality improvement tool  to help assess  LTC residents with acute changes in condition.

The primary care physicians (PCP) frequently complain that nurses do not provide an adequate description of the resident's condition and omit important details when giving reports. Due to this, the physician states he is unable to make appropriate diagnosis and treatment of a resident’s condition. He feels it is safer to send the resident to the emergency room to diagnose and treat (D&T). This problem can be solved with good knowledge and better communication skills.

In one facility where I worked I had received this complaint from the medical director when I had questioned the frequent orders for D&T. I decided to provide additional education for the nurses on all shifts. I developed a scenario of the most common illnesses and occurrences. Based on the INTERACT program, I had the nurses identify signs and symptoms, the appropriate information to provide to the physician and suggestions for inhouse care and treatment. I gave the nurses one week to complete each written assignment and where necessary, I provided additional inservice and also reinforced the documentation aspect.

All nurses were very compliant with the task and after three months the results were phenomenal. We had greatly decreased the number of residents transferred for D&T, the physicians were very impressed with the improved reporting skills of the nurses. The nurses had increased their knowledge and self confidence. Many nurses thanked me by saying “I learned so much”. They became more aware of the disease entities and appropriate observation skills.  Above all, the residents were treated quickly and appropriately and resources were not wasted.

We should always understand and use the tools available to us. The INTERACT program was always available but had not been used appropriately.

Many physicians and some facilities have Nurse Practitioners (NP) assigned to the practices and residents. This can be an added benefit as the NP can see the resident within a brief period of time and can provide a diagnosis and treatment plan. However, the PCP and the family must be notified timely. Documentation must be complete and thorough.

I hope this blog provided some useful information on what can be done as nurses to help decrease hospital readmissions in your facility. Never forget that we are the residents advocates and it is our responsibility to be prudent and resourceful in our care.