Decreasing Readmissions at

Discharge

Presented by: Courtney Norris, Nicholas Weida and Brooke Wilsman

Background How we formulated the PICO question

Good Samaritan Hospital in Lebanon, PA

Problems with hospital readmissions

Currently uses the teach-back method

http://www.ema.net/the-good-samaritan-hospital-.html

PICO Question

In the elderly population, will identifying barriers to readmission coupled with

creating interventions to combat the barriers decrease hospital readmissions as

compared with the standard teach-back method?

Learning Objectives

1. The learner will indicate three concerns for the discharge nurse to discuss over the phone with the recently discharged patient.

2. The learner will identify key assessment techniques that should be included in the admission of the geriatric client in the hospital.

3. The learner will uncover what aspects of care the geriatric population wish to include in their own discharge plan.

4. The learner will be able to identify risk factors and barriers that can cause hospital readmission.

Elderly Client Concerns at DischargeThe elderly like to be involved with discussing:

Time of discharge

When the patient goes home

Community Health

Dependency on public careers

Fear of not receiving accurate care

Not getting medical follow-up

Practical Matters

Housekeeping

Shopping

Answering the phone

Being able to secure their doors properly

Medications

(Foss and Askautrud, 2010)

http://alzheimershomecarenj.com/home-care-after-hospitalization-understand-the-role-of-the-hospital-discharge-planner/

Comparison of Values in Recently Discharged Elderly PatientsValues differ from each perspective

Elderly values:

Personal Care - Caregiver options

Mental Ability - carrying out everyday activities

Autonomy

Relatives of the elderly values:

Safety and security

Caregiver burden

Psychological well-being

Healthcare professionals values:

Autonomy

Finance

Social Contact

(Denson, Winefield, and Beilby, 2013)

https://www.burnaby.ca/Our-City-Hall/City-Departments/Engineering/Safety-and-Security.html

Teach Back Method Better Than Discharge Instructions?Evidence says no

There was no significant difference between:

Medication adherence

Therapeutic alliance

Patient’s experience

Readmissions

Many studies continue to articulate inconsistent results

(Hyrkas and Wiggins, 2014)

http://www.teachbacktraining.org/

Risk Factors for Hospital Readmission●Certain comorbidities cause an increased risk for hospital

readmission○ Hypertension

○ Diabetes mellitus

○ Chronic obstructive pulmonary disease

○ Congestive heart failure

○ Coronary artery disease

○ Dementia

○ Stroke

○ Chronic kidney disease

○ End-stage renal disease

○ Pressure ulcers

(Bogaisky and Dezieck, 2015)

https://www.dred.com/signs-and-symptoms-of-hypertension.jpg

https://gigaom.com/wp-content/uploads/sites/1/2014/01/diabetesmeter.jpg

Who is at risk?Nursing home residents have been found to be more at risk for being

readmitted to the hospital than the elderly population that live independently in the community

Often have higher levels of comorbidities and a lower functional status when compared to the elderly that live independently

More likely to be readmitted from complications of congestive heart failure and dementia

Have higher rates of diabetes, coronary artery disease, congestive heart failure, end-stage renal disease, and dementia than the elderly that live within the community

More likely to be nonverbal during their hospital stay

Live in a unique environment with access to health care providers daily

Have greater risk of mortality during their hospital stay than those that live in the community

(Bogaisky and Dezieck, 2015) http://f.tqn.com/y/seniorhealth/1/W/b/s/467305389.jpg

What about the community-dwelling elderly?●Post-discharge readmissions are often related to fragmented care

and adverse drug events

●Traditional discharge instructions often overlook the functional gaps related to these patients due to living independently

●Many elderly adults living within the community have barriers or “missing pieces” that enable them from properly caring for themselves once they leave the hospital

(Greysen et al, 2014)

http://blog.nolo.com/immigration/files/2014/02/puzzle-w-missing-pieces.jpg

Functional LimitationsMobility and instrumental activities of daily living

Shopping, cooking, and cleaning were found to be some of the main difficulties faced at home

Muscles become atrophied after being immobile at the hospital for an extended period of time

Function within the homeMany elderly patients have reported to forgetting the obstacles

in the home that can delay care

Difficulty with going out of the homeDepletes the needed reserves of recovering

Using more energy

Most errands take longer to do

May have to ask for help to do things that were once done independently

(Greysen et al, 2014)

http://growingleaders.com/blog/wp-content/uploads/2010/07/muscle-atrophy.jpg

Social IsolationUnable to interact

Often stay home due to lack of energy and strength from hospital stay

Support from others slowly diminishTransportation difficulties

Coordinating schedules became too difficult

Lack of social supportFrom progressive illness and loss in functional abilities

Loss of connection with friends

Social isolation can lead to loneliness and depression which makes it more difficult to recover from hospitalization

(Greysen et al, 2014)

http://www.alternet.org/files/styles/story_image/public/story_images/social_isolation.jpg

Challenges from PovertyCertain conditions or diseases can cause someone to lose their job

and even their home

Depending on the area where the patient resides, it can worsen their illness from contributing factors in the community

Physical features of home and community can threaten their well-being

Living in smaller environments with more people often make the susceptibility of contracting an illness more likely

(Greysen et al, 2014)http://i.dailymail.co.uk/i/pix/2013/07/22/article-2372951-05BE14010000044D-765_634x420.jpg

Implementing Interventions at AdmissionHospitalists trained to perform comprehensive admitting assessment

tools

Tool includes

Geriatric History and Physical Form

Fall Risk Scale

Caregiver Capacity

Healthcare Proxy

Home Setup Evaluation Tool

Practices r/t Home Medication Regimen

ADL Scale

Notification form to PCP on admission

https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=673&q=doctors+doing+admission+assessments&oq=doctors+doing+admission+assessments&gs_l=img.3...16657.23783.0.24728.35.13.0.22.2.0.150.1157.8j4.12.0....0...1ac.1.64.img..1.13.1101.HVA8KAe6vpI#imgrc=x_BpSGNXa52ncM%3A

(Courtney et al, 2009)

Implementing Interventions during HospitalizationIncorporate daily appointments with Physical Therapist to provide

various exercise routines

Multi-disciplinary Team Coordination during hospital stay Physical Therapy

Occupational Therapy

Nutritionist

Social Work

Home Care Nursing PRN

Recommendations based on perspectives after evaluation

Collaboration of recommendations to Hospitalist

Daily education regarding medications and disease process

(Dehia et al 2009)

https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=673&q=multiple+health+care+professionals&oq=multiple+health+care+professionals&gs_l=img.3...2467.10778.0.11198.36.15.2.19.21.0.127.1174.14j1.15.0....0...1ac.1.64.img..0.26.1226.Y2as4sKtjI8#imgrc=j0dGSEY1pdsr4M%3A

Implementing Interventions at DischargeDischarge includes the Discharge Planning Nurse, Discharge Planning

Hospitalist, and patient

All collaborative recommendations from health care professionals discussed

Written discharge instructions with large font and simple language

Easy-to-navigate grid on medications

Exercise routine provided by PT

Consult for Home Care Nurse implemented(Dedhia et al, 2009)https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=673&q=multiple+health+care+professionals&oq=multiple+health+care+professionals&gs_l=img.3...2467.10778.0.11198.36.15.2.19.21.0.127.1174.14j1.15.0....0...1ac.1.64.img..0.26.1226.Y2as4sKtjI8#hl=en&tbm=isch&q=hospital+discharge&imgrc=m94Vo6HWat9EdM%3A

Implementing Interventions after DischargeFollow-Up Phone Conversations with patient and Discharge Planning

Nurse48 hours after initial discharge along with Home Care Nurse visit

Weekly phone calls for 4 weeks

Monthly phone calls for 5 months

Nurse to Patient discussions includeTransitional Concerns

Assessment of further home visits with Public Health Nurse

Accessibility of resources

Medication knowledge

Ways to adapt to disease process

Exercise routines practiced with home care PT

(Courtney et al, 2009)

https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=673&q=multiple+health+care+professionals&oq=multiple+health+care+professionals&gs_l=img.3...2467.10778.0.11198.36.15.2.19.21.0.127.1174.14j1.15.0....0...1ac.1.64.img..0.26.1226.Y2as4sKtjI8#hl=en&tbm=isch&q=telephone&imgrc=bn15z_Ze8UwRoM%3A

Rates of Readmission StatisticsOnly 3% of patients were readmitted back to the hospital within

3 days after the comprehensive admission assessment and discharge plan was implemented (Dedhia et al, 2009)

Only 14% of patients were readmitted back to the hospital within 30 days after the comprehensive admission assessment and discharge plan was implemented (Dedhia et al, 2009)

https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=673&q=multiple+health+care+professionals&oq=multiple+health+care+professionals&gs_l=img.3...2467.10778.0.11198.36.15.2.19.21.0.127.1174.14j1.15.0....0...1ac.1.64.img..0.26.1226.Y2as4sKtjI8#hl=en&tbm=isch&q=readmission+&imgrc=DRzp8fCH0tTHvM%3A

Rates of Readmission StatisticsOnly 22% of patients were readmitted back to the hospital within

30 days after the exercise and follow-up phone call regimen was implemented (Courtney et al, 2009)

67% of patients reported a higher quality of life after the exercise program and follow-up phone call regimen was implemented (Courtney et al, 2009)

https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=673&q=multiple+health+care+professionals&oq=multiple+health+care+professionals&gs_l=img.3...2467.10778.0.11198.36.15.2.19.21.0.127.1174.14j1.15.0....0...1ac.1.64.img..0.26.1226.Y2as4sKtjI8#hl=en&tbm=isch&q=readmission+&imgrc=gxzxDwRXcnkFPM%3A

RecommendationsRecognize that many elderly have different values as healthcare

providers

Be aware that teach-back is as effective as simply telling them information

Implement multiple healthcare professionals with discharge

Allow interdisciplinary communication to occur with every patient

Work with case management to evaluate needs for Home care nursing

Physical therapy

Occupational therapy

Social work needs

Recommendations ContinuedAssess patients for barriers that may affect their ability to care for

themselves at home

Identify who is at risk for being readmitted

Know the functional limitations of your patient

Understand the social and financial aspects of their life to identify any other missing pieces that may not be physically evident

ReferencesBogaisky, M., & Dezieck, L. (2015). Early hospital readmission of nursing home residents and community-dwelling elderly adults discharged from the geriatrics service of an urban teaching hospital: Patterns and risk factors. Journal of the American Geriatrics Society, 63(3), 548-552 5p. http://dx.doi.org/10.1111/jgs.13317

Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: A randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. Journal of the American Geriatrics Society, 57(3), 395-402. http://dx.doi.org/10.1111/j.1532-5415.2009.02138

Dedhia, P., Kravet, S., Bulger, J., Hinson, T., Sridharan, A., Kolodner, K., & Howell, E. (2009). A quality improvement intervention to facilitate the transition of older adults from three hospitals back to their homes. Journal of the American Geriatrics Society, 57(9), 1540-1546. http://dx.doi.org10.1111/j.1532-5415.2009.02430

Denson, L. A., Winefield, H. R., & Beilby, J. J. (2013). Discharge-planning for long-term care needs: the values and priorities of older people, their younger relatives and health professionals. Scandinavian Journal of Caring Sciences, 27(1), 3-12 10p. http://dx.doi.org/10.1111/j.1471-6712.2012.00987.x

References ContinuedFoss, C., & Askautrud, M. (2010). Measuring the participation of elderly patients in the discharge process from hospital: a critical review of existing instruments. Scandinavian Journal of Caring Sciences, 2446-55, 10p. http://dx.doi.org/10.1111/j.1471-6712.2010.00788.x

Greysen, S. R., Hoi-Cheung, D., Garcia, V., Kessell, E., Sarkar, U., Goldman, L., & ... Kushel, M. (2014). 'Missing pieces'-functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. Journal of the American Geriatrics Society, 62(8), 1556-1561 6p. http://dx.doi.org/10.1111/jgs.12928

Hyrkas, K., & Wiggins, M. (2014). A comparison of usual care, a patient-centered education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute-care setting. Journal of Nursing Management, 22(3), 350-361 12p. http://dx.doi.org/10.1111/jonm.12221