What’s the most important factor in preventing unnecessary readmissions?

Johns Hopkins is working to improve patient- and family-centered care by reducing the number of patients who are discharged and then readmitted to the hospital within 30 days. Take the poll and cast your vote for the best way to improve a patient's transition of care from the hospital to the home. Then share your thoughts.

What’s the most important factor in preventing unnecessary readmissions?

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What’s the most important factor in preventing unnecessary readmissions?, 4.0 out of 5 based on 1 rating

10 Comments

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Raj K August 4, 2014 at 9:44 am

I would think finding the root cause, collect and analyze data from interviewing care takers and family members.Design creative and Targeted Solutions taking all Stakeholders into consideration.Create a methodology to identify high risk for readmission before discharge.Have a dedicate team of healthcare professionals to educate the patient and caretakers based on risk score before discharge.Have a concrete after discharge follow up plan .

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Nikki July 29, 2014 at 8:06 am

Too many readmissions occur due to post-op infection. I have a good friend that landed back in our hospital due to an extreme infection. We need to do a better job with preventing this type of thing. Hopkins is very innovative, but we fall down in this area.

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Dee July 28, 2014 at 1:05 pm

This is a multiple answer question and too difficult to narrow down, but my hope is the leadership will truly read this first-hand experience and make changes. This is a double edge sword, we are always trying to create beds as fast as possible to eliminate the back up in the ED, but then we discharge premature only to bring patients right back in the ED and readmit. What has that saved? Nothing and caused terrible upset and often pain for the patient. When you are “waiting side” for hours or days to be admitted you pray for someone to be discharged so you can get your loved one in after grueling tests and labs and lying on the hard steel bed. But when your loved one is the “inpatient side” and docs want to discharge and you don't feel they are ready, you see the other side. I can tell you I spent 8 mths last year with my mom between JHH, Bayview, GBMC and 2 nursing homes. She never went home after her first admission and was transferred back and forth between facilities with a total of 6 admissions. One of our READMISSONS was less than 24 hrs, because her physicians wouldn’t listen to me when I said she was clearly not ready to leave and they thought so. She was readmitted for several days. The most frustrating problem, which I believe would be a tremendous help for the whole system would be for 1 Sr. Doc to track a patient when a patient stays longer than 3 days, each rotation doesn't really read the chart, they don't have time and offend don't seem to care about your frustrations. The other BIG problem is you cannot have doctors telling a patient everything from instructions/problems etc when they can hardly tell where they are. There needs to be DAILY communication from 1 regular physician so progress can be made instead saying ok we can't do anything more, it has improved some she is going back to the nursing home where they cannot handle a very ill patient, the patient immediately backslides only to be readmitted. I had to beg endlessly to get information, everywhere she was and I was her medical power of attorney. The last 8 mths of my mother's life, I worked my 8 hr shift and then lived the rest by my mom's side so she could get the care she needed from me because she was so sick she could have used an aide all by herself. She was diagnosed with Crohns Disease in March and died in August at 69, which in my heart I think she could have been saved by better care. I could give detailed pros and cons after all of these hospital stays. The saddest part was I don't think there was one doctor that saw my mom who ever really seemed determined to save her or put this in remission, after each rotation you never heard a thing until they came back and said oh I see you are back again or still here. We had some awesome techs & nurses, but we had some that were horrible and made it obvious that Crohns symptoms were problems they didn't have time to deal with and annoyed because she need such frequent care. My mother did not die from Crohns, but passed from SEPSUS while she was an inpatient, how does this happen? I apologize for the length, but it gives the full picture of how readmissions continue to happen. I’m sorry but I just expected more from the #1 hospital.

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Yvonne July 28, 2014 at 11:39 am

Incomplete medication reconciliation prior to discharge
Clear instructions with patient or family caregiver prior to discharge.
I agree with the comment above that the current system in place focus on how soon a patient can be discharged.

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Cynthia Huesman July 28, 2014 at 9:57 am

I think that the patient needs to be carefully assessed to see if they are ready to be discharged. If not, they should remain hospitalized until they are ready to be discharged. There needs to be an adequate plan in place for how the patient will receive care, what that care should be and from whom it is going to be given prior to the patient being discharged. Follow-up phone calls/visits might need to be arranged to ensure that proper care is being administered once the person is home.

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Bonnie C July 28, 2014 at 9:21 am

All of the other comments already submitted are valid concerns. However, I work in Radiology and frequently there is a need to do specialized radiographic services before discharge (for a complete diagnostic "picture"), and there isn't an opportunity (availability of a scanner, for instance) to get the imaging done. So, the patient is either held another day, or readmitted (primarily due to insurance not wanting to pay for an outpatient exam, especially so close to discharge). We need to develop a protocol for inpatients having priority, and, perhaps, using the outpatient scanners from time to time, to make sure all imaging and other tests are complete before discharge. Then the patient needs to be properly instructed at discharge for any follow-up actions (medication, bandage change, etc.). Making sure all discharge instructions are given in writing as well as orally, and making sure the discharging staff takes time to answer any questions, and ascertain that the patient really knows what needs to be done, is also very important. Too often the patient just wants "to go home" and doesn't really listen to what follow-up is necessary.

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mcl July 28, 2014 at 9:00 am

My experience shows that all the reasons for being in the hospital are not resolved and stabilized before discharge. Blood tests, X-rays and all the other diagonostic evidence are fine, but listening to the patient is the most important factor in preventing unnecessary readmissions. The discharge instructions are very important, but if you haven't had your major issues resolved. It is far to late to: Prevent probably readmission; provide the best hospital care; prevent further issues for the patient whether it is a readmission or not.

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susan Rice July 28, 2014 at 8:07 am

i worked as a public health nurse, in home care for many years, now in research.
from my time in both positions, patients need the most basic repetitive instructions, and re-instructions for once they get home. it always amazes me to see a pt, who has no idea about meds, or follow up care, once home. They are overwhelmed, and home is often not the orderly, regimented place that the hospital is. they need a couple of clear instructions, and ONE number to call with a person to talk to for questions.
if medications can be confused, they will be once a pt gets home. good d/c planning is critical.

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kn July 28, 2014 at 7:43 am

We seem to do quite well at admitting patients, developing a differential diagnosis, and initiating treatment. AND then we seem to lose interest. If we put as much effort into safe, effective and efficient discharge as we do diagnosis and treatment, we would be in a million dollar position - no pun intended. My experience has been that our "system" does not engender this work.

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Linda French July 28, 2014 at 7:41 am

Inadequate discharge. Too sudden, too hurried, often bad timing ( ie: d/c between 5pm&5am or late Friday) lack of understanding by the PT & family regarding overwhelming instructions, lack if quality time to ensure patient/ family understand, paperwork from Epic confusing and lacking specific/ induvidualized detail, no assistance in making f/u appt.

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