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Question About Readmission in a Hospital


The issue of hospital readmissions has been identified as a source of unnecessary Medicare costs; according to Hugh & Ma (2013), costs for readmissions make up over fifteen billion dollars each year. Therefore, studying how readmissions can be eliminated can lead to the reduction of costs that may be put towards improving patients’ outcomes. Even though various interventions (post-discharge care or target transitional care) have the potential to be promising, the findings of the research on the topic are mixed and vague.

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To formulate a more specific research question regarding the issue of hospital readmissions, it is important to focus on a patient population that can participate in the further research and a specific intervention that will facilitate the reduction of readmission rates. Thus, the specific research question is “Is there a connection between transitional care interventions and a reduction of hospital readmissions among Medicare patients with heart failure?”

Literature Review

According to the study conducted by McHugh and Ma (2013), improvements targeted at enhancing nurses’ environment in a healthcare setting along with appropriate staffing decisions have the potential to be effective in preventing readmissions of Medicare patients with heart failure, acute myocardial infarction, and pneumonia. This conclusion was made based on the investigation of admission and readmission rates with a connection to an average nurse’s workload. It is important to account for the workload in the context of a transitional care model, which encompasses an extensive range of services and environments targeted at promoting safe and timely passages of patients between various levels of care settings (Naylor & Keating, 2008). The transitional care model calls for immaculate coordination between health providers and thus has a direct impact on the workload of nurses since it overlaps other forms of care (primary care, care coordination, case management, etc.) (Agency for Healthcare Research and Quality, 2014).

The study conducted by the Agency for Healthcare Research and Quality (2014) found limited evidence of transitional interventions reducing 30-day readmissions of patients with heart failure. On the other hand, strong evidence was found for home-visiting programs and MDS-HF clinic interventions being beneficial for improving rates of all-cause readmissions from three to six months. Apart from the two types of mentioned interventions, STS interventions were also efficacious in reducing mortality rates among patients. Moreover, only a few trials analyzed in the research reported whether transitional model interventions decreased or increased visits to the ER (Agency for Healthcare Research and Quality, 2014).

Research conducted by Jackson, Trygstad, DeWalt, and DuBard (2013) reviewed data about 21,375 Medicaid patients with complex chronic conditions. Patients included in the transitional care group were experiencing higher possibilities of risks compared to regular patients; moreover, a larger portion of them had chronic conditions. The study showed the effectiveness of a transitional care model among patients with chronic conditions regarding the readmissions after discharge. The reduction of readmission risks was achieved through Community Care of North Carolina’s transitional care intervention that focused on Medicaid patients. The study by Jackson et al. (2013) contributed to the growing number of literature that suggested that cohesive and targeted care interventions can aid in reducing readmissions among patients of high risk.

The study conducted by Franks (2015) found that the implementation of the evidence-based protocols and practices of transitional care could contribute to the reduction of readmissions to hospitals that negatively impact the health outcomes of the elderly population. It was concluded that hospital readmissions could positively influence the healthcare facility operations by enhancing the quality of health care, patient satisfaction, as well as reduction of healthcare costs. Furthermore, the study underlined the importance of education for nurses required for the implementation of appropriate transitional care practices targeted at elderly patients who are usually at a higher risk of 30-day readmissions.

Similarly to previously mentioned studies, Lee (2016) found that the transitional care model had the potential to positively influence the rates of readmissions among cardiac transplant patients. According to his findings, the study group pf patients that experienced transitional care interventions had a readmission rate of 8.3% compared to 36.8% in the group that did not receive transitional care (Lee, 2016). Transitional care offered patients coherent and safe transitions from hospitals to their homes, thus reducing the rate of 30-day readmissions. Therefore, this study supported the hypothesis that an intervention program associated with transitional care could significantly improve the quality and safety of care in a healthcare setting (Lee, 2016).

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Research conducted by Long (2012) targeted elderly patients with heart failure or Chronic Obstructive Pulmonary Disease, using a DNP-led transitional care program. At the end of the transitional care program, the readmissions rate decreased from 20 to 0 in a 30-day period, which suggests that the implemented interventions had a positive impact on the provision of care and thus on the readmission rate. Furthermore, in the 30 days, the rate of ER utilization for COPD and HR-related symptoms also reduced to 0.


The study will include 40 patients that experienced heart failure and had to undergo treatment in a healthcare facility. Half of the patients will be subjected to a transitional care model while the other half receives other types of health interventions to compare the health outcomes at the end of the experiment. It will also be beneficial to involve a Quality Improvement team of the healthcare facility in measuring the results of interventions and assess the rates of readmissions among two groups of patients. Qualitative data on readmission rates within the 30 days will be gathered from patient profiles and compared to the data on two patient groups.

Convenience sampling will be the most suitable because the patients included in the study should be available near the researcher, and they all have to undergo treatment in the same healthcare facility to make sure that they receive equal care. While a great proportion of patients with heart failure will be excluded from the study, convenience sampling will be beneficial for reducing costs and saving time.

No special equipment or tools will be required for researching the aim of the scholar will be to gather and review patient data before and after the interventions. The algorithm of data gathering and analysis will start from the collection of preliminary data on patients that were admitted to the facility to receive treatment. After the implementation of transitional or non-transitional interventions, patient data will be gathered to analyze the outcomes. Then, any data on readmissions of patients involved in the study will be collected to see whether the group of patients with heart failure who received transitional care in the facility show better readmission rates compared to those receiving other types of healthcare interventions.


Agency for Healthcare Research and Quality. (2014). Transitional care interventions to prevent readmissions for people with heart failure. Web.

Franks, S. (2015). Transitional care to reduce 30-day heart failure readmissions among the long-term care elderly population. Web.

Jackson, C., Trygstad, T., DeWalt, D., & DuBard, A. (2013). Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions. Health Affairs, 32(8), 1-9.

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Lee, J. (2016). Transitional care intervention to reduce 30-day readmission rate in cardiac transplant patients. Web.

Long, M. (2012). Using a DNP-led transitional care program to prevent rehospitalization in elderly patients with Heart Failure or Chronic Obstructive Pulmonary Disease. Web.

McHugh, M., & Ma, C. (2013). Hospital nursing and 30-day readmissions among Medicare patients with Heart Failure, Acute Myocardial Infarction, and Pneumonia. Med Care, 51(1), 52-59.

Naylor, M., & Keating, S. (2008). Transitional Care: Moving patients from one care setting to another. American Journal of Nursing, 108(9), 58-63.

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