Introduction
Approximately one-fifth of elderly patients are readmitted within 30 days after having been discharged from American hospitals, and almost 50 percent of these readmissions are considered to be preventable (Verhaegh et al., 2014). The cost of readmissions after hospitalization amounts to $12-$44 billion annually (Verhaegh et al., 2014).
Overview
There has not been a substantial change in the proportion of Medicare population suffering from various adverse events following hospital discharge. According to a study of readmissions rates among patients with heart failure, more than 25 percent of individuals hospitalized because of it is readmitted with the following month (Rennke et al., 2013). In order to address the problem, the Centers for Medicare & Medicaid Services started reducing financing of hospitals with excessively high readmission rates, in an attempt to incentive their management for developing effective policies for supporting a safe transition of care.
The patient-related factors contributing to the increased risk of readmission include, but not limited to, multiple chronic illnesses such as chronic obstructive pulmonary disease and renal disorders among others, and previous readmission within a period of six months (Verhaegh et al., 2014). The main organizational factors causing the problem are “poor communication between inpatient and outpatient clinicians, medication changes during hospitalizations” (Rennke et al., 2013, p. 435), inadequately standardized discharge process, and the absence of proper follow-up arrangements.
Interventions aimed at the reduction of the risk of readmission and facilitation of the safe transition of elderly patients from hospital to home are being referred to as transitional care interventions (Rennke et al., 2013). Their main focus is on the prevention of poor health outcomes caused by uncoordinated care through caregiver education, increased coordination among health care professionals, and reconciliation of medication (Rennke et al., 2013). Previous research on the effectiveness of discharge interventions indicates that “discharge planning, self-management education, and follow-up after discharge” (Verhaegh et al., 2014, p. 1532) have the potential to reduce hospital readmission rates.
Taking into consideration the fact that the percentage of the elderly population of the U.S. is expected to grow significantly in the following decade, it is hard to overstate the importance of the problem to nursing. Therefore, it is necessary to find an evidence-based approach to solving the problem within the framework of the transitional care model (TCM). As of now, there are significant variations between intervention measures aimed at reducing the risk of hospitalization. It means that there is a need for a universal approach to reducing both short-term and long-term readmissions.
The aim of this research is to assess the effectiveness of existing transitional care interventions in order to determine the most effective strategies for reducing readmission rates. The following research questions will be investigated in this research:
- Q1. Is there a connection between transitional care interventions and a reduction of hospital readmissions among Medicare patients?
- Q2. What are the most effective transitional care measures in terms of their intensity?
The topic of research is aligned with the following essentials of master’s education in nursing: quality improvement and safety, translating and integrating scholarship into practice, and clinical prevention and population health for improving health (AACN, 2011).
Conclusion
The problem of excessively high readmission rates should become a national health care priority. The research will examine the link between transitional care interventions and a reduction of hospital readmissions among Medicare patients. It will also look at the most effective transitional care measures in terms of their intensity.
References
AACN. (2011). The essentials of master’s education in nursing. Web.
Rennke, S., Nguyen, O., Shoeb, M., Magan, Y., Wachter, R., & Ranji, S. (2013). Hospital-initiated transitional care interventions as a patient safety strategy. Annals of Internal Medicine, 158(5), 433-439.
Verhaegh, K., MacNeil-Vroomen, J., Eslami, S., Geerlings, S., de Rooij, S., & Buurman, B. (2014). Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Affairs, 33(9), 1531-1539.