Reduce Readmissions and Improve Transitional Care Services: An Interdisciplinary Team Provides Effective, High-Quality Discharge Care

By McLaughlin, Frances; Henn, Joyce et al. | American Nurse Today, December 2017 | Go to article overview

Reduce Readmissions and Improve Transitional Care Services: An Interdisciplinary Team Provides Effective, High-Quality Discharge Care


McLaughlin, Frances, Henn, Joyce, Candelario, Danielle, American Nurse Today


THE AFFORDABLE CARE ACT contains regulations that tie financial incentives to the quality and efficiency of health care that hospitals deliver. For example, the Hospital Readmissions Reduction Program addresses 30-day all-cause readmissions for multiple conditions, including acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure, and pneumonia. The Centers for Medicare & Medicaid Services (CMS) penalizes hospitals that have a 3-year rolling readmission rate beyond a risk-adjusted average rate; the penalty is based on a percentage of reimbursement.

Research shows that communication failure during care transitions plays a role in readmissions and emergency department (ED) visits. Other frequent causes for readmissions include lack of follow up, failure to fully reconcile medications, and a lack of knowledge about medication side effects. Studies strongly indicate that interventions at the time of discharge decrease readmission rates.

These interventions require additional time to educate patients about their care plan and medications, to schedule an office visit with the provider, and to present patients with easy-to-read instructions. Our tertiary academic medical center created the care transition center (CTC), a centralized discharge unit that provides high-quality, effective discharge care to reduce readmissions and ensure smooth transitions.

How does the CTC work?

The CTC targets patients who are being discharged to home or transferred to subacute facilities with a diagnosis of heart failure, AMI, COPD, or pneumonia (community acquired, aspiration, and sepsis coded pneumonia on admission). Patients are identified in the electronic health record (EHR) as "high risk for readmission" by the medical and nursing care providers using the protocol order, which states: "Risk for readmission criteria met, on discharge please send patient to the care transition center." This order may be placed by the provider, nurse, pharmacist, or case manager

As part of their discharge, patients and their care-givers are transported to the CTC for education about their illness, coordination of durable medical equipment, scheduling of follow-up appointments, medication reconciliation, and prescription services. For patients going home, an individualized plan of care is designed in collaboration with the patient using evidence-based measures to decrease readmission, including early signs of decompensation, individualized medication education, information about how to obtain medications, and scheduling follow-up appointments with community providers. Patients being discharged to a subacute facility receive a pharmacist medication reconciliation and disease management education according to their individual needs. (See How the CTC process works.)

CTC staff use the teach-back method to ensure patients and their caregivers understand their postdischarge instructions, follow them, obtain appropriate follow-up care, and know when to seek additional help.

The CTC operates Monday through Friday during peak hours of discharge (9:30 AM to 7:30 PM). The interdisciplinary, collaborative CTC team consists of two RNs, one pharmacist, two patient care associates (PCAs), and one secretary. The RNs assess each patient for health literacy, disease state management, and self-care knowledge. Instructions are provided in writing, verbally, and through demonstration. In conjunction with the patient, RNs also assess home management of diet, activity, work, and social obligations. Incorporating practitioner orders, nutritional guidelines, and activity recommendations, an individualized plan of care is developed.

The pharmacist then instructs the patient (using dem onstration, motivational interviewing, and the teach-back method) about his or her medications, encouraging the use of prescription services before leaving the hospital. Medication indication, use, storage, side effects, and disposal are discussed. …

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