1. Resources for Nursing Whitepaper 2013
Article Summary presented by Lena Matyas, MSN,BSN,RN,DSW

2.  Medicaid payment reduction (CMS)
program
 Initial patient population focus: AMI,
CHF, Pneumonia (PN)
 In 2015 COPD , Total Hip, Total Knee
were added as additional measures
(CMS.gov 2014)

3.  Lack of support at home, low health
literacy
 Admitted for CHF,AMI, PN, recent
hospitalization, ER visits
 Disease burden: 6 or more
medications, CHF, DM,COPD, Mental
Health, cancer and chemical
dependency
(Agency for Health Care Research and Quality,2011)

4.  Disability, poor nutrition
 Discharge over the weekend or holiday
 Adverse medication events
 Failure to take medication as directed
(Agency for Health Care Research and Quality,2011)

5.  Gaps in care during the hospitalization, especially
issues related to patient safety, infections and
inaccurate medication reconciliation at admission
and/or discharge.
 Patient’s lack of understanding D/C plan including:
medication schedule and/or warning signs of a negative
change in condition and/or what are the steps they
need to take should the signs/symptoms occur
 Patient’s non-compliance with any or the entire D/C
plan (AHA, 2011)

6.  Breakdown in communication between
care providers in different disciplines
 Lack of follow-up with Specialists or
PCP. PCP is often unaware of the
hospitalization
(AHA,2011)

7.  Staffing level and heavy workload for nursing:
 Each additional patient for nursing workload can
increase:
◦ The chance of readmission by 7% for CHF patient
population
◦ The chance of readmission by 6% for PN patient
population
◦ The chance of readmission by 9% for AMI patient
population
(McHugh & Ma, 2013)

8.  Transition Plans implemented to decrease
preventable admissions
 Patients who followed up with their PCP within 7
days of discharge are less likely to be re-
admitted
 Nurses spending more time on patient education
( Askren-Gonzales, 2012)
 Nurses’ work environment: Implemented
Transition Plans increased workplace satisfaction
for nurses, and decreased hospital readmission
rates for patients
(McHugh & Ma, 2013)

9.  Enabling nurses to improve communication
between inpatient and outpatient providers
 Utilizing “teach back” method with patients as
often as possible (Oh,2011)
 Creating positions such as “Nurse Discharge
Advocate” (e.g. RED pilot program). The advocates
would work with patients who are identified as
“high-risk” for readmission and play an active role
in the process from admission to discharge. Nurse
Discharge Advocates also coordinate follow-up
care in the community as well as making sure that
patients understand the signs of complications
when they should seek out medical advice
(Reengineered Hospital Discharge Program (RED) by Jack, et. al 2009)

10.  Nurse Discharge Advocates spending additional
time to assure that discharge instructions
including medication management are well
understood. The medication instructions include
dosing instructions and the reason for taking the
medication (CSC Preventing hospital readmissions, 2012).
 Home monitoring: include practices such as
health coaching, tele monitoring and advice lines
available to call. Health coaches would meet the
patient prior to being discharged from the
hospital.

11.  2/3rd of the patients fail to take their
medications as directed mostly due to
knowledge deficit
 Many patients fail to have follow-up visits with
PCP. PCP is unaware of the hospitalization
(Herzog, 2013)
 Routinely F/U calls within 24-72 hours after
discharge is often ineffective if patient is
advised to F/U with PCP (Patients will not F/U
with PCP)

12.  Increasing role of remote tele-monitoring at home
can reduce re-admission rate
 Health coach would F/U with patients with
additional education on medications , D/C
instructions and coordinate additional services.
 Pilot study-all cardiac patients D/C-ed with tele-
monitoring device were followed by D/C nurse who
would explain device’s purpose and use. When
transmission perceives risk, insurance nurse would
check on the patient. Readmission rates for cardiac
patients were reduced by 47% and inpatient stay
reduced by 60% (Harrison et. al 2011 and Oh, 2011)

13.  Although this group might have been familiar
with the risk factors for re-admissions, we
can learn valuable lessons from pilot studies,
and data that is available for analysis to
consider implementing solutions and
evaluate findings for our advantage.

14. Questions and
Comments
For questions on this presentation please
contact: milena.matyas@mainegeneral.org

15. Agency for Healthcare Research and Quality (2011). Conditions with the largest number of adult hospital
readmissions by payer, 2011. Retrieved from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-
Conditions-Readmissions-Payer.pdf.
American Hospital Association ( September, 2011): Examining the Drivers of Readmissions and Reducing
Unnecessary Readmissions for Better Patient Care
Retrieved from: http://www.aha.org/research/reports/tw/11sep-tw-readmissions.pdf
Askren- Gonzales, Angela (2012): Deployment of lean six sigma in care coordination: an improved
discharge process. Professional Case Management, 17(3):117-23.
Centers for Medicare and Medicaid Services (2012): Readmission reduction Program. Retrieved from:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS
/Readmissions-Reduction-Program.html
CSC(2012): Reducing hospital readmissions: The fist test case for continuity of care. Global Institute for
emerging healthcare practices. Retrieved from:
http://assets1.csc.com/health_services/downloads/CSC_Preventing_Hospital_Readmission.pdf
Harrison P., Hara, P. Pope J. E., Young, M. P., and Rula, E. (2011): The Impact of Post discharge telephonic
follow-up on hospital readmissions. Population Health Management 14(1),27-32.
DOI:10.1089/pop.2009.0076
Herzog, Robert (2013): 5 Ways Healthcare Providers Can Reduce Costly Hospital Readmissions. Retrieved
from:
http://hitconsultant.net/2013/03/31/5-ways-healthcare-providers-can-reduce-costly-hospital-
readmissions/

16. Jack, W. Brian, Chetty, V. K., Anthony, D., Greenwald, J. L.; Greenwald, J. l., Sanchez, G. M., Johnson, A.E.,
Forsythe S.R., O’Donnell., Paasche-Orlow M.K., Manasseh, C., Martin, S. and Culpepper, L. (2009): A
reengineered hospital discharge program to decrease re-hospitalization. Annual Internal Medicine, 150 (3)
178-187.
Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738592/
Oh, Jamie (2011): 10 proven ways to reduce hospital readmissions. Retrieved from:
www.beckershospitalreview.com/.../10 proven-ways-to-reduce-hospital- readmissions.html