Preventing Readmission to the Hospital

Preventing readmission doesn’t end when a person leaves the hospital. When you receive a new client, you accept the responsibility to do everything you can to help that client follow discharge instructions. Dropping the ball on crucial post-discharge activities can quickly, and sometimes unnecessarily, land clients right back in the hospital.

CLIENTS ARE AT RISK FOR READMISSION IF THEY:

Have CHF, pneumonia, COPD, mental illness or GI problems.
Take more than 5 medications.
Live alone and/or lack support.
Don’t understand their medical condition(s).
Don’t have a primary care physician.
Did not receive adequate teaching about the discharge instructions.

THINGS TO CONSIDER:

Are medication instructions clear?
Is the client able to discuss his/her medical condition?
Is the client making and keeping necessary medical appointments?
In addition to your help, does the client have support from friends, family and/or the community?

OTHER IMPORTANT POINTS:

Preventing readmissions to the hospital is a team effort. One person, or even one group of people cannot do it all. There has to be a plan, good communication and accountability from the staff at the hospital, the nursing home and/or the home care agency, and no one is exempt from responsibility.
Preventing readmission starts the moment a person is admitted to the hospital. Hospital staff do everything they can to educate clients about their conditions, teach them what to do to stay healthy after discharge and set up community resources to support clients along the way. When the care is handed off from the hospital, the responsibility to prevent readmission lies with the new care team.
Caregivers like you are vital to preventing readmissions because you are the main link between the client and the rest of the team. You spend the most time with the client. You are in the best position to observe changes in symptoms, side effects of medications, and non-compliance with medications, therapies or suggested lifestyle changes.