Population Health Problem
The problem under focus is the high level of avoidable readmissions among ethnically diverse patients who have chronic conditions. It is a known fact that statistically, Hispanic and African American people are more likely to be readmitted into a hospital than White people are (Centers for Medicare & Medicaid Services, 2018). However, aside from the evident racial disparity, there is another worrying observation – most of these readmissions could be avoided. Understanding the reasons behind racial disparity in readmissions is essential in ascertaining proper ways of addressing this issue.
Ethnically diverse patient with chronic conditions constitute the main group, which will be the focus of this study. Avoidable readmissions among non-white patients is a relevant problem because of two major factors. First, readmissions are a substantial burden on national healthcare finances. Out of $26 billion spent on patients who are readmitted each year, $17 billion stem from cases that could have been avoided (Centers for Medicare & Medicaid Services, 2018, p. 1). Second, disparity in readmissions is a disconcerting sign of health inequity. On average, black patients are twenty times more likely to be readmitted than white patients are (Figueroa et al., 2018). As a result, both the state and the ethnically diverse population of people with chronic conditions suffer from the inefficiencies and disparities in healthcare delivery.
This problem is relevant to nursing practice due to the direct involvement of nurses in healthcare delivery. Patient care presupposes working with numerous people of different ethnicities. Furthermore, readmissions are an indication of insufficient healthcare quality during the initial admissions. All factors leading to disparities and subsequent readmissions can be observed by nurses due to their direct involvement in the administration of treatment and communication with patients.
Evidence from Literature
Evidence from the literature is mostly consistent with the actual nursing practice. For instance, the observation that educating patients on post-discharge care is essential in preventing readmissions can be supported with real examples (Valente et al., 2020). Reviewing the source of data allows ascertaining the accuracy of data – many studies choose samples that are not representative of the general population. The variety of real-life cases is too wide to be covered by studies limited by sample size.
There are three major barriers impeding the implementation of measures, which would decrease the rate of readmissions. First, studies note the lack of coordination between hospital care and post-discharge care, with many instances where advanced care planning is not included at all (Pugh et al., 2021). Many patients do not receive the same level of attention in outpatient settings that is available in hospitals, which leads to further deterioration of health. Second, both medical professionals and patients have significant time constraints that prevent them from adequately addressing the ongoing medical condition (Pugh et al., 2021). Third, trust issues between the medical staff and patients are frequently reported, many of which are based on ethnicity (Valente et al., 2020). Subsequently, measures that would ensure proper disease self-management after a discharge are not implemented, resulting in the perpetual cycle of readmissions.
The criticism found in current research regarding the effectiveness of policies aimed at preventing readmissions focuses on three major points. First, post-discharge care is most effective when it is provided with multicomponent interventions, such as consistent and frequent phone calls, medication reconciliation, and regular observation (Pugh et al., 2021). Second, post discharge care produces the most satisfactory results, when patients are actively included in discharge and follow-up care planning (Pugh et al., 2021). Third, the most effective communication transpires when the medical staff adopts respectful and transparent communication styles, which prevent conflicts on the racial basis (Valente et al., 2020). Overall, the existing literature actively advocates for the necessity of these measures for increasing the effectiveness of policies.
The current literature promotes a concept of a nurse as a person responsible for patient education. When patients are discharged, they are no longer under constant medical observation. As a result, all decisions regarding the subsequent course of action should be made by the patient. When armed with appropriate knowledge, patients can properly handle disease management (Pugh et al., 2021). Nurses are in the most convenient position to educate patients because most of healthcare interactions transpires between them (Rice et al., 2018). The rapport resulting from continuing interaction allows nurses to actively influence patients to have a more responsible attitude towards their follow-up care.
The conceptual framework guiding actions of nurses is formed by case-based decision theory. Its main idea is that actions should be based on previous experience in the same situation with the same patient (Glette et al., 2018). The most important decisions regarding inpatient and outpatient care are made by physicians. However, they base their choices on the information delivered by nurses (Glette et al., 2018). As a result, aside from properly administering required treatment, communicating with patients and educating them, it is essential for nurses to make and report important observations regarding the condition of their patients.
Effect of Governmental Policies on Readmissions
The Hospital Readmissions Reduction Program (HRRP) is a Medicare program aimed at reducing disparities in readmissions as well as readmissions themselves. The essence of this program is to penalize hospitals with high rates of readmissions. This policy is based on the assumption that an avoidable readmission is a fault of nurses and physicians delivering the healthcare. The HRRP helps ethnically diverse patients with chronic conditions by incentivizing hospitals to improve inpatient care, discharge process, and follow-up care. The better the quality of healthcare during the initial admission is, the less likely patients are to be readmitted.
However, the policy of fines has faced substantial criticism from academic circles. The most prominent issue with the HRRP is that it is not effective. The program has been in effect since 2010 – more than a decade. Yet, there was no statistical evidence of significant changes in the number of readmissions. The largest reduction that did transpire happened between 2008 and 2014 – the percentage of readmissions fell by 2.1% (Gupta & Fonarow, 2018, 1172). Not only did the population not benefit significantly from the implementation of this policy, but the mortality rate following hospitalizations also increased (Gupta & Fonarow, 2018). This statistic has led the researchers to suggest financially incentivizing post-charge care instead of penalizing the rate of readmissions.
A common theme in literature on nurses is the essential role of nurses in healthcare delivery as well as policy-making. However, researchers argue that most nurses do not actively exert influence on the creation of new policies despite constituting the majority of healthcare workforce (Hajizadeh, 2021). Nurses are important because they have first-hand knowledge of any developments in hospitals. Nurses are the first to observe all negative consequences of the unsuccessful policies, such as the HRRP (Glette et al, 2018). By sharing their insight with physicians and policy makers, nurses have the capacity to make meaningful changes that would improve overall delivery of healthcare and the readmissions rate as well.
The prevalence of the HRRP directly influences the nursing practice. The main implication of this program is that hospitals seek to avoid penalties by either delaying the readmissions or substituting them with alternatives to hospitalization (Gupta et al., 2018). As a result, additional pressure is put on nurses to ensure that patients are educated enough to be able to properly manage their conditions after the discharge. Nurses have to subtly communicate to patients that they are unlikely to be readmitted in the immediate aftermath of the discharge and should be prepared to handle their illness in an outpatient setting.
Leadership Strategies
Three leadership strategies can be identified in the literature pertaining to the problem of disparity in readmissions. The first is facilitating social connections, which implies creating an atmosphere of trust and support among nurses and patients, thus having a positive impact on the laters’ education (Weil et al., 2019). The second strategy is promoting positivity, which manifests in creating and maintaining proper mood among patients that will help them recuperate (Weil et al., 2019). The third strategy is conveying altruism, which presupposes that nurses adopt a selfless attitude towards helping patients (Weil et al., 2019). However, the necessary precondition for the effectiveness of these strategies is the sufficient amount of time that will allow fostering proper relationships.
Regardless of the chosen strategy, leadership is important for the prevention of readmissions and disparities. The current rates of readmissions are a direct consequence of the systemic inefficiencies. It is evident that the HRRP has failed and has not resolved the problem. With no new policy looming on the horizon, it is important that nurses leaders are able to organize the nursing staff to educate patients on their conditions and properly communicate to physicians and policy makers. Effective nurse leadership will provide guidance to patients, which is essential in post-charge disease management.
Addressing the problem requires implementing a collaboration strategy and a communication strategy. The collaboration strategy will require nurses to intensify their interactions with physicians who determine the course of treatment. The more informed of the patients’ condition, physicians will be, the less likely the patients are to be readmitted. Meanwhile, the communication strategy will ensure the transparency and clarity of intentions. Nurses need to adopt transparent communication styles that will convince ethnically diverse patients that no racial prejudices among the healthcare staff exist. Not only will it improve relationships between patients and medical professionals, but it will also reduce disparities in healthcare delivery.
Finally, two change management strategies will be essential in preventing readmissions. First, it is important that nurses participate in policymaking and voice their opinion on the necessity of certain changes, such as implementing financial incentives for proper post-discharge care. The second strategy is to advocate for finding alternatives to readmissions. An example of a facility that would provide adequate care without hospitalization is a nursing home. Implementation of this strategy requires nurses to discuss with patients available options of continuing post-discharge care, which do not necessitate hospitalization.
Volunteer Experience Form
Site Contact Information
Direct Care Contacts:
- Lynda Whitefield
- Paul Jameson
- Anthony Watkins
Direct Care Contact Relationship:
- Subject Matter Expert (Lynda Whitefield)
- Patients (Paul Jameson, Anthony Watkins)
Direct Care Contacts Email Address:
Direct Care Contacts Telephone:
- +1.888.381.9462 (Lynda Whitefield)
- +1.888.471.2385 (Paul Jameson)
- +1.888.762.5823 (Anthony Watkins)
Volunteer Experience Total Hours
The entirety of activities transpired over the course of three days and took nine hours in total.
How were your volunteer hours spent?
- Talking or meeting with the patient, family, group or industry subject matter expert to assess the health problem you have identified.
First, I have reached out to two patients, one of whom was African American with a chronic heart condition – Paul Jameson. The other patient was Anthony Watkins, who was Hispanic with Diabetes Type II. Initially, I used an email to introduce myself and ask for help with the assessment of the problem of disparities in readmission. Both men were recently discharged from hospitals where they were admitted twice. The meetings themselves transpired on a skype platform, with each taking two hours in total.
I asked about their opinion on the prevalence of the concern regarding disparities. Both of them agreed that this issue exists and confided that their initial hospitalizations were not fully effective. After the discharge, their condition gradually worsened and they had to be readmitted. I asked what prevented them from recuperating during the initial hospitalization. Their answer implicated nurses who showed reluctance to pay attention to their medical concerns and report them to physicians.
Then, I contacted a nurse Lynda Whitefield who shared her insight into the reasons for readmissions and disparity. She accentuated poor communication between nurses and patients and low level of collaboration between nurses and physicians. Lynda also elaborated on hospitals’ intention to avoid financial penalties for the high rate of readmissions, which often result in worsening quality of healthcare. Lynda believed that policy changes are essential in order to reduce disparities and readmissions.
Site Contact Acknowledgment
All participants communicated with me on a voluntary basis and provided insight into the studied health problem from both the patient’s and nurse’s perspective.
References
Centers for Medicare & Medicaid Services. (2018). Guide to reducing disparities in readmissions. Web.
Figueroa, J. F., Zheng, J., Orav, E. J., Epstein, A. M., & Jha, A. K. (2018). Medicare program associated with narrowing hospital readmission disparities between black and white patients.Health Affairs, 37(4), 654-661. Web.
Glette, M. K., Kringeland, T., Røise, O., & Wiig, S. (2018). Exploring physicians’ decision-making in hospital readmission processes-a comparative case study.BMC Health Services Research, 18(1), 1-12. Web.
Gupta, A., & Fonarow, G. C. (2018). The Hospital Readmissions Reduction Program—Learning from failure of a healthcare policy. European Journal of Heart Failure, 20(8), 1169-1174.
Hajizadeh, A., Zamanzadeh, V., Kakemam, E., Bahreini, R., & Khodayari-Zarnaq, R. (2021). Factors influencing nurses participation in the health policy-making process: A systematic review. BMC Nursing, 20(1), 1-9.
Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., & Leykum, L. (2021). Evidence based processes to prevent readmissions: More is better, a ten-site observational study. BMC Health Services Research, 21(1), 1-11. Web.
Rice, H., Say, R., & Betihavas, V. (2018). The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review.Patient Education and Counseling, 101(3), 363-374. Web.
Valente, J., Johnson, N., Edu, U., & Karliner, L. S. (2020). Importance of communication and relationships: addressing disparities in hospitalizations for African-American patients in academic primary care.Journal of General Internal Medicine, 35(1), 228-236. Web.
Wei, H., Roberts, P., Strickler, J., & Corbett, R. W. (2019). Nurse leaders’ strategies to foster nurse resilience. Journal of Nursing Management, 27(4), 681-687.