1. PREVENTION OF READMISSIONS By Michael Burns Widener University

2. Hospital Readmissions Readmission refers to a patient's being admitted to a hospital within a certain time period from an initial admission. Medicare generally defines readmissions as patient’s being hospitalized within 30 days of an initial hospital stay. Factors that affect readmissions, including patients' diagnoses and severity of illness; patients' behavior, such as adherence to discharge instructions; and the availability and quality of post discharge care.

3. Issue of the organization Nursing is responsible for part of the high readmission rate due to lack of discharge teaching. The institution has an admission discharge team that does not take part in discharge teaching. The team only does paperwork for the patient. Patients are not given adequate amount of discharge education prior to leaving the hospital. Reducing readmission has shown to be a difficult task but nursing involvement has been shown to aid in this reduction.

4. Readmissions and change theory Lewin’s Change Theory is a model that will be used to examine nursing responsibilities in patient readmissions to hospitals. This theory has three major concepts: driving forces, restraining forces, and equilibrium (Sarayreh, Khudair, & Barakat, 2013). Driving forces in the prevention readmissions of patients are nurses, case managers, social workers and physicians. The restraining forces in the prevention of readmissions of patients are time, family support, and written discharge material. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered by changes that occur between the driving and restraining forces (Sarayreh, Khudair, & Barakat, 2013).

5. Change Theory: Unfreezing, Change, and Refreezing Unfreezing is the process which involves finding a method of making it possible for people to let go of an old pattern that was somehow counterproductive. The change stage which is also called the movement stage, involves a process of change in thoughts, feeling, behavior, or all three, that is in some way more liberating or more productive (Sarayreh, Khudair, & Barakat, 2013). The refreezing stage is establishing the change as the new habit, so that it now becomes the standard operating procedure (Sarayreh, Khudair, & Barakat, 2013). 21 days to break a habit?

6. Importance of the issue 15-25% of people who are discharged from the hospital will be readmitted to the hospital within 30 days or less, and that many of these readmissions are preventable (Laudicella, Donni, & Smith, 2012). Nursing can assist with this prevention. The patients certainly would not mind having fewer hospitalizations, and billions of dollars in spending on hospital stays could be saved if these hospitalizations could be avoided. Patient with chronic disease are thought to be the majority of patients who are readmitted to the hospital. Heart Failure and COPD alone account for 9% of all medical admissions (Stone & Hoffman, 2010) This could suggest that better management of the patient's condition could prevent both the initial hospitalization as well as readmissions (Stone & Hoffman, 2010). Medicare pays $15 billion each year to cover the costs of readmissions, of which $12 billion is for cases considered to be preventable (Stone & Hoffman, 2010).

7. Facilitators of Change Reimbursement is a major facilitator of change. Hospital reimbursement will be affected if patients are readmitted to the hospital within 30 days from the same diagnosis according to new health care insurance guidelines. Hospital leadership will create changes in the organization to protect the reimbursement for the hospital. Insurance company’s Government

8. Barriers to Change Adherence to discharge instructions Language or poor cognitive function Stress Family support or involvement

9. Risks of Change Reduction of readmissions to hospitals should not be viewed as a change in this health organization. Nursing adherence to change Employee engagement

10. Benefits of Change Patient’s health and safety. Major financial benefits for both hospital reimbursement and insurance company’s.

11. Possible Outcomes Increasing quality of life for patients. Decreasing hospital readmissions. Standardizing an nursing discharge plan that has positive benefits to all patients to prevent hospital readmissions.

12. How to Change Patients often are at risk for readmission while in transition between sites of care. Examples of these transitions include hospital to home, rehabilitation facility to skilled nursing facility, and home care agency to hospital. Education will be the most important modifiable change that nursing can be involved with to prevent hospital readmissions. Paying for what works in health care.

13. How to Change cont. Using health Informatics to improve quality and integrate care across settings. Examples of health informatics include: electronic health records, patients registries, and risk stratification software. Teaching at a level that is appropriate to the patient in which they can understand. Watching how we use medical terminology.

14. What Can Nursing Change? Discharge teaching done early and multiple times when patient still in the hospital. Discharge teaching done with family or support members of the patient. Becoming transition coaches. Maintaining a lifeline! Using post discharge follow up phone calls. Telemonitoring. Frequent follow up visits by nursing.

15. MAWDS Heart Failure Mnemonic M: Medication: Take you medication at the appropriate time. Create a medication cassette to store medications. A: Activity: Stay active each day. Exercise is important component in heart failure patients. W: Weight: Weigh yourself each day. Patients should contact their primary care provider if they notice a 3-5 pound increase over 2-3 days. D: Diet: Follow your diet. Sodium management and restriction is important due to the retention of water. S: Symptoms: Recognition of your symptoms. Shortness of breath, fast heart rate, fluid retention, increased fatigue.

16. Nursing Discharge Team Using staff that is already developed. Working with the patient to develop a patient specific plan. Meetings with patient and patient support person. Create patient centered care plans.

17. Hospital Team Nursing organizations running hospital readmission reduction programs. Strategies formulated by a team of nurse and nurse leaders.

18. Closing Comment With all of the changes that nursing can control preventing many hospital readmissions is an achievable goal that the organization I work for can accomplish.

19. References Laudicella, M., Donni, P. L., Smith, P. C. (2012). Hospital readmission rates: Signal of failure or success? Imperial College Business School, 1-31. Sarayreh, B, H., Khudair, H., Barakat, E. (2013). Comparative study: The Kurt Lewin of change management. International Journal of Computer and Information Technology, 2 (4) 226-229. Stone, J., Hoffman, G, J. (2010). Medicare hospitals readmissions: Issues, policy options and PPACA. Congressional Research Service, 1-39.