6 ways to prevent hospital readmissions

How to get the information you need

To prevent hospital admissions, hospital staff should gather as much information as possible about the patient's discharge needs, psycho-social needs, and support systems in the community, says Cory Sevin, RN, MSN, NP, director with the Institute for Healthcare Improvement. They should talk to family members and primary care providers who know the patient and can provide first-hand information, Sevin says.

Here are five more tips from the experts on how you can keep your patients from being readmitted to the hospital:

• Staff should look for barriers, such as cost or lack of transportation, that could prevent patients from receiving post-acute treatment, and problem-solve before the patient leaves the hospital.

Staff should work with patients to make sure that they can pay for any outpatient services or medications that are not covered by insurance, and help them get assistance if they can't pay. If something isn't covered by their insurance, contact the doctor to see if the treatment plan can be changed, suggests Donna Zazworsky, RN, MS, CCM, FAAN, vice president of Community Health and Continuum Care for Carondelet Health Network in Tucson, AZ.

• Staff should make sure that chronically ill patients have the equipment they need to monitor their conditions after discharge and know how to use it, Zazworsky suggests.

For example, make sure patients with diabetes obtain a glucometer that is covered by his or her health plan, she adds. If possible, provide the glucometer before the patient leaves the hospital.

Push disease management

• Help patients with chronic illnesses enroll in a disease management program, Zazworsky recommends.

• Make sure patients and caregivers understand the patient's condition, medication regimen, red flag signs and symptoms, and who to call if they occur, Sevin suggests.

Use the teach-back method to make sure patients and caregivers understand, rather than just lecturing them.

• Staff should implement a good hand-off to the providers in the next level of care, whether it's a rehab facility, skilled nursing facility, home care nurse, or physician.

Staff should make sure they have all the information about the patient's reason for hospitalization, medications, test results, plan of care, and discharge plan along with the ability to use the teach-back method to educate patients. Instead of waiting weeks after discharge to send the information, staff should create a system to transmit it in a timely way, Sevin recommends.