AJN, American Journal of Nursing:
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Revamping nurses& roles in discharge and follow-up can save billions and keep patients healthier.
Newly discharged patients don't stay out of the hospital for long, report Jencks and colleagues in a recent review of Medicare claims data from 2003 to 2004. Nearly 20% return within 30 days and about two-thirds come back or die within a year. The estimated cost of unplanned readmissions? Almost a fifth ($17.4 billion) of Medicare's annual hospital payout.
Figure. A recent stu...Image Tools
Of course, the severely sick sometimes need more than one round of inpatient care, but research suggests that return visits are largely preventable. Half of patients rehospitalized within a month, for instance, didn't see a physician for follow-up in the interim. And infection and pneumonia, both potentially the result of poor postoperative self-care, sent surgical patients to the hospital nearly as frequently as their original complaint did.
In short, once patients leave the hospital, they're not getting the guidance they need. "There's a real opportunity here for nurses," said AARP president Jennie Chin Hansen, a member of the Medicare Payment Advisory Commission. "It's an occasion for them to think about the role they play in the patient's segue from the hospital to the outside community. Yes, they're working for a specific institution, but their collective concern is the well-being of the individual." Hansen advocates nurse-led teams who track patients after discharge, which addresses a major problem highlighted by the Medicare study findings: currently, no single entity is accountable for the patient at all times. In response, policymakers are not only exploring programs that coordinate care between physicians, home aides, and family members, they're also tinkering with financial incentives that reward hospitals for reducing the number of patients who return.
There's ample room for change across the country. Rates of hospital readmission in the east and northeast far outstripped those in the midwest and northwest; 30 days after being discharged, only 13.3% of Idahoans landed back in the hospital, for example, whereas nearly twice as many Washington, D.C., residents (23.2%) did.
As the Obama administration hashes out the finer details of how to overhaul payment plans and tweak follow-up systems, nurses, Hansen said, might consider how their everyday interactions affect people's long-term health. About the discharge process, she said, "It's not just about giving instructions. The minute the patient is wheeled out the glass doors, the caregiver has the responsibility of doing just what the nurses were doing five minutes ago. So we should be mindful that it's a very high-stress time." About the transition from hospital to home care in general, she emphasizes thinking in terms of prevention. "We should be teaching families early on to look for swollen ankles," she said, by way of an example. "It's a whole different way of looking at wellness, one that's about early maintenance and prevention, rather than cleanup. There's a real chance here for nurses to be proactive."
Jencks SF, et al. N Engl J Med 2009;360(14):1418–28.
© 2009 Lippincott Williams & Wilkins, Inc.