Nurse-Led Strategies for Preventing Avoidable Readmissions

Topics: Nursing, Readmissions, Quality, Performance Improvement

By reading this study, members will learn:

• The near-term, mid-term, and long-term impact of readmissions on hospital finance
• Strategies for expanding readmission prevention efforts beyond a disease specific approach
• Strategies for focusing efforts on the most preventable readmissions
• Strategies for leveraging the inpatient stay to equip patients for long-term self-management
• Strategies for facilitating seamless transfers to the post-acute care setting

Executive Summary

Newfound urgency to prevent readmissions

While clinical leaders have an ongoing interest in reducing readmissions to improve care quality, economic forces have pushed the issue even further into the national spotlight. With research indicating that nearly 20% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, there is now widespread consensus that the nation’s health care system could save billions by preventing avoidable readmissions.

Substantial opportunity for clinicians to curb readmissions

Recognizing that not all readmissions can—or should—be avoided, many hospital clinicians are asking an important question: What proportion can caregivers actually prevent?

To answer this question, Kaiser Permanente of Southern California studied unplanned readmissions at two facilities and found that only 25% of unplanned readmissions resulted from patient noncompliance. The remaining 75% were attributed to “systems issues,” which leaders at Kaiser perceived as directly within hospital clinicians’ control.

Three nurse-led strategies to reduce avoidable readmissions

To prevent avoidable hospital readmissions, we recommend that hospital leaders:

• Expand readmission prevention efforts beyond a disease-specific approach and focus on all patients at high risk of readmission.
• Ensure interventions are narrowly focused on specific drivers of potentially preventable readmissions and not “all-cause” readmissions.
• Strengthen coordination of care within and across multiple settings to ensure patients receive appropriate care across the continuum.

Read the full study to learn more

Nurse-Led Strategies for Preventing Avoidable Readmissions provides tactics for executing this three-part readmission prevention strategy, with an in-depth focus on the third and most challenging component: strengthening coordination across the care continuum.

To help nursing leaders identify their organization’s most pressing needs, the study begins with a readmission prevention red flag audit. The subsequent practices equip clinicians to leverage the inpatient stay to prepare patients for long-term self management and to facilitate seamless transfers to post-acute care settings.

Readmission Prevention Strategy Red Flag Audit