| Primary Author: | Patricia E. Moran, RN, ANP-C, DNP-student |
| Organization | Stony Brook University, School of Nursing |
Abstract
Purpose
The purpose of this study was to evaluate the effect of a care coordination model, designed to reduce readmission, on a group of transitioning at-risk elders. The goal of the model is to improve patient education, communication between inpatient and outpatient providers and implement timely follow-up visits.
Background
It is estimated that the health care system could save $26 billion over ten years by decreasing hospital readmission. The Centers for Medicare and Medicaid Services would like a 20% reduction in hospital readmission rates by the end of 2013, which could prevent 1.6 million hospitalizations and save an estimated $15 billion. Beginning in fiscal year 2013, hospitals can expect denial of reimbursement for patients readmitted within 30 days for heart failure, pneumonia, or MI. Hospitals will have reimbursement reduced by 1% or less while penalties in 2014 and 2015 will be capped at 2% and 3%.
Materials & Methods
The model was initiated on a 30-bed medical floor of an academic medical center over a six month period. Eligibility criteria included all male and female patients over 70 years of age, taking five or more medications, lived at home and discharged back to home.
Results
All eligible patients (N=100) received the intervention and were included in the sample. Over the six-month period, readmission decreased from 19% to 15%. For 11% (n=11), of the sample, the index admission was a 30- day readmission. For this group 27.3% (n=3) were again readmitted within 30 days. Descriptive statistics were analyzed for the entire sample. Patients who were readmitted within 30 days and those who were not were also compared.
Conclusion
Identifying high risk patients at the time of admission and coordinating care across transitions is integral to prevention of unnecessary readmission. Implementing a smooth transition from the hospital to the community, communication with primary care physicians, and improving patient and family readiness for discharge have a direct impact on hospital readmission rates.
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© Improvement Science Research Network, 2012
The ISRN published this as received and with permission from the author(s).