Readmission indicates the organization’s quality of care and portrays the effectiveness of post-discharge care. A patient could be admitted to the hospital again for the second time for not receiving proper care, poor instructions upon leaving, or not being clear enough. The Affordable Care Act has worked towards a decrease in readmission rates and cost reduction. The Center for Medicaid and Medicare Services states that about one in five Medicare patients discharged from the hospital return and are admitted within 30 days (Rau, 2018). The hospital is facing this challenge, resulting in a penalty imposed by Medicare for all patient payments. The purpose of this memo is to develop strategies to deal with the 30-day readmission rate for our patients.
Readmission after hospitalization for common cardiac conditions such as heart failure is extremely common, especially in older adults. To improve healthcare quality and reduce costs, the government of the United States has put increasing pressure on hospitals to decrease preventable readmissions. Following the passage of the Affordable Care Act in 2012, the Federal government began directing financial penalties toward hospitals with higher-than-expected 30-day readmission rates (Nastars et al., 2019). The total medical payments may be reduced to 3% for hospitals with the highest 30-day readmission rates for publicly reported conditions (Rau, 2018). Despite these changes, scientific literature has not provided clear guidelines on reducing preventable re-hospitalization. Our organization has faced the challenge and has necessitated the need to implement strategies that will help us cope with the issue of readmission and possibly escape the imposed penalty by Medicare.
Redesigning the care coordination continuum across the system will be essential for the change strategy. This will ensure that we have linkage in activities and communication promptly. We must understand the continuum of care as patients move through the hospital in the outpatient world. Care coordination is critical to avoid inconsistencies and a poorly planned continuum. It will be geared toward the safety of the patients and the health quality that we offer to the patients. The pros of this strategy are that it will bridge the gap remaining pre-active with the patients’ health. After discharge, the strategy will always ensure that the patient gets quality management to foster recovery. The cons for this strategy may include the heavy workload we already have in the institution. There may be challenges associated with relationships with the circle of care. Redesigning care coordination in the continuum will not incur any cost.
Patient education will be critical to address the issue of readmissions. Education for the patients will be essential to empowering them to become champions of their health. Some patients do not adequately understand the conditions, treatments, and how to manage their symptoms. Health literacy will be needed to educate the patients on the benefits of following the care plan. Patients who do not follow the care plan may lack proper recovery, resulting in readmission (Borsuk et al., 2019). Patients will be educated on the need to take medication and go for a follow-up appointment to check how they are faring after being discharged from the hospital. The patients additionally receive education on adopting a healthy lifestyle which is essential for a healthy body.
The pros of patient education are that at all times, the patient will have the information needed to improve health and promote recovery after discharge. The patient will be able to care for themselves to ensure they do not need readmission. The cons of the strategy are that the patient may not value the education provided and that conflicts and lack of coherence in education may arise. There may be little free time to promote patient education. The cost needed for implementing this strategy will be approximately $4050 for transport and allowances to the trainers and medical staff who will travel out of the facility to check patients in their homes.
The hospital will need to develop a community and local approach to healthcare for the significance of reducing readmissions. The process will proceed by proactively building relationships with other community organizations. These relations will enable the organization to have better partners in the community to provide necessary resources for patients who have been recently discharged. Community organizations such as those related to diet will ensure the patient can be observed to prevent malnutrition in staking essential nutrition requirements that may influence their ability to recover properly (Castro et al., 2020). Other amenities may include the gym for exercise and recreational parks that may help with the psychological needs of the patients. This strategy’s main advantage is ensuring that the patient has access to needed resources to promote recovery and prevent readmission. The cons of the strategy are that there may be a lack of collaboration from the communities. Lack of communication and public participation may hinder the strategy’s success. Developing a community and local approach to care will incur a cost of $3358 for paying meeting allowances for experts who will facilitate the program.
Multidisciplinary teams will be implemented for the significance of discussing and sharing information on patients. The teams will ensure that every member responsible for the patient’s care, such as social workers, nutritionists, and nurses, is involved in efficient information sharing. This concept will be significant to ensure that no misunderstandings are recorded. Unity of the teams will ensure that the rights information is passed at all times concerning the patient and the patient’s health, and they will receive adequate care that prevents them from readmission. Incorporating the teams will be a good opportunity for the members to spend time with the patients to communicate their knowledge. Hospital leaders and clinicians will utilize management to track the patients across the continuum and help increase communication between providers and their patients. The cons of this strategy will be miscommunication between disciplines, lack of motivation, and poor decision-making. Implementation of the multidisciplinary team will not incur any cost to the organization.
Post-acute services will be available to the patients, and ease of access will help reduce readmissions. Post-acute services will ensure the patient receives care even after discharge hence curbing issues resulting in readmission. Patients, especially those from rural areas, may not have access to primary care. The strategy’s pros are that it will ensure access, promote a more straightforward healing process, and reduce the chances of health problems after discharge. The barrier to the strategy will be a lack of proper funding and a lack of compliance from the patients in receiving post-acute care. The cost that the strategy will impose on the organization is $10200 for training the staff and making necessary adjustments of personnel to facilitate the changes.
We will need to set the verbal vision and mission regarding the challenge of readmission. Measurable goals will be set and assessed on the rates and certify that we work towards reaching the goals. Leaders need to demonstrate the importance of why we need to implement the change strategies every move and any barriers that may hinder the process (Borsuk et al., 2019). The pros of the strategy are that the organization will always know its objectives of preventing readmission, working to achieve a common goal, and being a source of motivation to attain it. The cons of the strategy will be limited time, lack of resources, and resistance from faculty. There will be no funding needed to implement this strategy in the organization.
Social factors that influence patient readmissions will be assessed vigorously. The factors may include homelessness, poverty, education, dietary needs, drug abuse, and transportation challenges. Social economics is essential for the healing process and communities with resources to provide patients with better outcomes. Many patients may not have the proper income and resources needed to foster a good healing process. Assessing the factors will be beneficial in tracking down any aspects that would encourage readmission. Challenges to the success of the strategy will be a lack of resources. The strategy will not require funding from the organization as the staff will create adjustments on their working time to schedule meeting the community members.
Our key responsibilities are to ensure the organization is running smoothly and promote quality care for the patients. The rate at which our patients are being readmitted has been a major challenge that necessitates immediate intervention. It is a shame that the hospital has had to be punished for its readmission rates which signifies that we are not headed in the right direction. The problem has resulted in the need for these strategies that I feel will be effective in countering the problem. I am requesting ultimate support for this organization’s success and improvement.
References
Borsuk, D. J., Al-Khamis, A., Geiser, A. J., Zhou, D., Warner, C., Kochar, K., & Marecik, S. J. (2019). S128: Active post-discharge surveillance program as a part of enhanced recovery after surgery protocol decreases emergency department visits and readmissions in colorectal patients. Surgical Endoscopy, 33(11), 3816-3827.
Castro, P. D., Reynolds, C. M., Kennelly, S., Clyne, B., Bury, G., Hanlon, D., & Corish, C. A. (2020). General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: A qualitative study. Clinical Nutrition ESPEN, 36, 116-127.
Nastars, D. R., Rojas, J. D., Ottenbacher, K. J., & Graham, J. E. (2019). Race/ethnicity and 30-day readmission rates in Medicare beneficiaries with COPD. Respiratory Care, 64(8), 931-936.
Rau, J. (2018). Medicare eases readmission penalties against Safety-Net Hospitals. Kaiser Health News. Web.