To prevent readmissions, coordinate services post-discharge

Take proactive approach to what happens beyond hospital walls

The best way to prevent hospital readmissions is to make sure patients are better managed and receive the care they need after they leave the hospital, states Donna Zazworsky, RN, MS, CCM, FAAN, vice president of community health and continuum care for Carondelet Health Network in Tucson, AZ.

In addition to reducing the length of stay, the goal of a discharge plan should be to prevent readmissions by improving the coordination of services the patient receives after discharge and by bridging the gap between the hospital and the patient's post-acute destination, whether the patient is going home or to a facility at another level of care, she adds.

Hospitals traditionally have been reactive rather than proactive when it comes to readmissions, and that needs to change, Zazworsky says, particularly as the Centers for Medicare & Medicaid Services (CMS) moves toward denying payment for patients with some conditions who are readmitted within 30 days of discharge.

"What hospital case managers need to do is look at what measures they can put in place to prevent patients from coming back," she says.

To ensure a smooth transition to the next level of care, make sure that the next clinician who will see the patient has timely information about what happened in the hospital, suggests Cory Sevin, RN, MSN, NP, director of the Institute for Healthcare Improvement, a Cambridge, MA-based nonprofit organization with the mission of improving health care.

"When somebody goes home, the primary care physician should be alerted and should receive information on what happened in the hospital, what medications were prescribed, and whatever other information they need to have to act on behalf of a patient. If a patient is going to another level of care, that provider should also have timely and comprehensive information," she says.

Lack of medical supervision in the community is one of the biggest factors in hospital readmissions, says Elaine Keane, vice president for business development for Visiting Nurse Services of New York, a home care organization that collaborates with hospitals in the area on programs to reduce readmissions.

With the advent of hospitalist programs in many hospitals, a patient's hospital episode is separate from what has happened with the patient in the community, Keane points out.

"For patients to have a successful stay in the hospital and transition to the community, providers need to share information across the continuum of care," Keane says.

A cross-continuum team that works together to improve transitions of care is a key component of the Institute for Healthcare Improvement's hospital collaborative, which bring teams from 30 to 60 hospitals and other organizations together over a 12-month period on process improvement projects to improve care, Sevin says.

Working with a cross-continuum team was a big factor in helping St. Luke's Hospital in Cedar Rapids, IA, reduce readmissions, adds Peg Bradke, RN, MA, the hospital's heart care services director.

"It's nice to have a comprehensive team. If you are just working within the hospital, you are missing the bigger picture. The representatives from the clinic, home health, and the post-acute facilities look at things from a different point of view from the hospital staff. Getting the patient's perspective is also a very important component of our program," she says.

Along those same lines, Zazworsky recommends working with community providers to develop memoranda of understanding with details on what information the hospital will provide and how the patients will get follow-up after discharge.

"Many patients are readmitted to the hospital because they don't have what they need to stay stable once they are discharged back into the community. If patients don't have the basic things they need to take care of themselves, it can derail a discharge," Sevin says.

For instance, patients need to understand their treatment plan and their medications, transportation to the pharmacy so they can get their medications right away, a follow-up visit with a physician within a week after discharge and a way to get there, and food that will be good for them, she says.

Look for barriers, such as cost and lack of transportation, that could prevent patients from receiving post-acute treatment and problem-solve before the patient leaves the hospital, Zazworsky suggests.

"There's a lot that hospitals need to take care of when they're getting ready to discharge someone. Ideally, the case managers should start on admission to understand the needs that the patients will have when they go home," Sevin says.

Make sure that you identify the family caregivers and whoever else needs to know what kind of care the patient will need after discharge, she says.

"It's really important for the case managers to fully understand the complex needs of their patients. They need to take a lot of care with the assessment process and not just interview the patient and check off the boxes," Sevin says.

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, Zazworsky says.

"It's important for case managers to understand their patients' health plans and, if something isn't covered, go back to the doctor and see if the treatment plan can be changed," she says.

To ensure a successful discharge, case managers should educate patients about their disease process and what can affect their recovery and make sure they have the resources to manage their disease.

They should coordinate all the multiple aspects of care the patient will need after discharge and make sure they are in place, Zazworsky says.

For instance, if patients have heart failure, give them a scale, and have them demonstrate how to weigh themselves and record it.

"If patients have trouble seeing the number on the scale, it doesn't do much good to ask them to weigh themselves," she adds.

Make sure patients with diabetes get a glucometer that is covered by their health plan before they leave the hospital.

"Have the glucometers available for them, because nine times out of 10 if they leave the hospital without a glucometer and are newly diagnosed, they won't get it for a few days. When they're in the hospital is an opportune time to make sure they know how to use the glucometer," she adds.

Help patients with a chronic disease such as diabetes enroll in a self-management program, she adds.

Create a tool box for your unit or the case management department as a whole that includes information on internal and external resources, community programs, and health centers, support groups, and resource booklets, she says.

When patients are frequently readmitted, drill down to determine why, Zazworsky suggests. For instance, if a patient with diabetes keeps coming back with sepsis or pneumonia, it may be because the diabetes isn't under control, she points out.

"Always look for ways to improve the system. Determine where pieces are falling through the cracks as patients transition and develop strategies to bridge the gap," she says.

Develop guidelines for patients at risk for rehospitalization, Zazworsky suggests.

For instance, her health system has created an action plan for hospitalized patients with diabetes that tells them exactly what to expect when they are in the hospital.

The patients also receive a card that outlines recommended tests and procedures and the optimal results. For instance, the card shows how often patients should have a hemoglobin A1c test and what the results should be.

Make sure that patients are prescribed appropriate therapies, such as beta blockers, statins, and insulin therapy at discharge, and that they understand how and when to take them.

Hospital case managers should give patients clear, concise, and comprehensive written information on how to take their medications, Zazworksy says.

She says one patient was supposed to take one medication three times a day and another five times a day but took them all before noon so he'd be sure to remember.

"As nurses in the hospital know, patients tend to refer to their medication as 'pink pills' and 'green pills' rather than being familiar with the medication name and what it's for. As community case managers, we see many patients who are not taking their medication properly," she points out.

Make sure the patients, family members, and caregivers understand what the medications are, when to take them, and make sure that they get their medications right after they are hospitalized, Sevin says. Make sure that they can pay for their medications, and if they can't help them connect with organizations that can help with the cost.

Develop a mechanism to identify high-risk patients who need help transitioning to the community, Zazworsky says.

Arrange for at least one home health visit for patients who are at risk for readmission, she adds.

Visiting Nurse Services of New York's program to reduce readmissions for heart failure program has resulted in a decrease in hospitalizations and emergency department visits for patients, Keane reports.

At one hospital, analysis of patient data before and after the program started showed that emergency department visits for heart failure patients in the program decreased by 40%, readmissions decreased by 41%, and readmission days dropped by 36%. At another hospital, data for about 300 patients are still being analyzed, but results show that rehospitalizations have been reduced, Keane adds.

The heart failure readmission programs are a collaborative effort between the Visiting Nurses Association and hospitals and is tailored to meet each hospital's specific needs, but all have similar components.

All heart failure patients who are admitted to the hospital are referred to the program. A nurse from VNS does a risk screening when the patient is in the hospital, starts the educational process, and offers the patient the opportunity to participate.

"The intake role has transitional care nursing embedded into it. When we work with patients in our heart failure readmission program, the intake nurse plays a broader role in terms of getting the care started and engaging patients in health education before they go home," Keane says.

Home care nurses visit the patients after discharge and conduct a comprehensive educational program over the course of several visits, as well as making sure the patients understand their medication regimen and have a follow-up visit with a physician.

"We work with the patients and their caregivers to develop treatment goals and a plan for what the patients should do if the symptoms present," Keane says.

(Editor's note: Donna Zazworsky's web conference CD "The Case Manager's Role in Transitioning to the Community" is available at

[For more information, contact:

Elaine Keane, vice president for business development for Visiting Nurse Services of New York, e-mail:;

Cory Sevin, RN, MSN, NP, director, Institute for Healthcare Improvement, e-mail:;

Donna Zazworsky, RN, MS, CCM, FAAN, vice president of community health and continuum care, Carondelet Health Network, e-mail:]