Readmissions Prevention (Review)

PSHC
Feb 11, 2025
13 min read

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READMISSIONS : PREVENTING A TRIP BACK TO THE HOSPITAL

The need for containing and reducing health care costs has been in the news for quite some time. A significant cause of high healthcare costs is hospital readmissions. In home health, readmissions, also called rehospitalizations, refer to patients who are discharged from an acute care hospital and are hospitalized again within 60 days of discharge.

Readmissions may have a financial impact on facilities. It also may have a significant impact on how partnering hospitals and most importantly beneficiaries view the safety and quality of care provided both in the hospital and at home. Home health agencies publicly report readmissions to hospitals. Hospital readmissions is a part of the CMS' five-star ratings, which identify agencies that achieve positive outcomes in patient care.

Home health staff play a key role in preventing readmissions. Proper observation, monitoring and documentation of patients' conditions will help limit the risk of complications.

Understanding Readmissions

Readmissions are classified as unanticipated, unscheduled readmissions to the hospital that are either related to or unrelated to the reason for admission to the home health agency. Although the person is typically returned to the original admitting hospital, a readmission occurs when the person is being admitted to any hospital for treatment.

Readmissions to the hospital place the patient at a greater risk of health care-associated infections and complications of care. The Agency for Healthcare Research and Quality identified that one in five hospital patients covered by Medicare are readmitted within 30 days. This costs Medicare approximately $15 billion dollars per year. Hospitals are financially penalized up to three percent of their regular reimbursement for readmissions. Hospitals with higher than expected readmissions within 30 days of discharge for the following diagnosis are included in the readmissions reduction program:

Chronic lung disease
Chronic Artery Bypass Graft Surgery
Heart Attacks
Heart Failure
Hip and Knee replacements
Pneumonia

Source: https://www.advisory.com/daily-briefing/2017/08/07/hospital-penalties

Transitions of Care

Transition of care refer to the movement of a patient between health care settings. Included in these transitions is from hospital setting-to-home or home-to-hospital setting. Ineffective care transition processes lead to high risk for hospitalizations. Problems identified during care transition include communication breakdowns such as not informing patient of care needed after discharge or not providing medication lists. Another common problem leading to poor transition of care is lack of patient education on follow up appointments or identifying the need for home health services.

With the fragmentation of care and chaos of having multiple providers for one patient, home health often remains the anchor in a sea of chaos for many patients transitioning home after a hospital episode of care. Home health can help patients understand their conditions, help with medications and recognize problems before they become more severe.

It's worth noting that front-loading home health series to provide 60% of planned visits in the first two weeks of the care episode has proven to lower readmission rates, along with weekly phone calls before the weekend to remind the patient/caregiver of when to call the nurse or physician to prevent an emergency room visit/hospitalization. It's obvious that home health has a vital role in preventing readmissions.

Relocation stress syndrome

Transitioning from one setting to another has the potential for causing or increasing confusion and traumatizing an elderly or sick patient. Signs and symptoms include:

Increased dependence
Delirium
Depression
Anger
Withdrawal
Changes in behavior
Changes in sleeping habits
Feelings of insecurity, loss of trust
Weight loss (or, less commonly, gain)
Falls

This is the phenomena known as relocation stress syndrome. Older terms that may still be used are transfer trauma and relocation shock. Transfer trauma is a consequence of the stress and emotional shock caused by an abrupt relocation of a patient from one location or agency to another, including the home. Unless a proposed transfer is emergent, involve the patient in planning for transfer.

Evidence suggests that ensuring continuity of care of elderly or sick people during care transitions improves patient outcomes, reducing the rate of avoidable readmissions.

Strategies for Prevention

Because home health can have an effect on readmission rates, it's import to implement strategies to prevent avoidable readmissions. The following are a series of strategies to help care for patients in this way.

Recognize red flags

Obtain information from the discharging agency of key points for patients/families (and home health providers) to monitor. This should include a written list of specific symptoms to watch for and what to do if they occur. (See Figure 45.1 for an example.) This will help you know who to call and when.

SAMPLE OF RED FLAG INSTRUCTIONS

(See figure FIGURE 45.1 below)

Medical problem: Heart failure

Call RN (phone number) Physician (phone number)

Increased shortness of breath especially when lying flat
Increased fatigue/weakness
Weight gain of 3 pounds in a day or 5 pounds in a week
Swelling in ankles
Irregular heartbeat

Call 911

Severe shortness of breath (unable to breath)
Chest pain unrelieved with medication
Frothy sputum

Medical problem: Diabetes (low blood sugar)

Call RN (phone number) Physician (phone number)

Dizziness, shakiness
Increased hunger
Headache
Changes in vision

Call 911

Loss of consciousness
Seizures

Medical problem: Respiratory (COPD)

Call RN (phone number) Physician (phone number)

Increased shortness of breath
Increasing cough
Change in color, thickness or amount of sputum
Loss of appetite
Fever greater than 101 degrees Fahrenheit

Call 911

Severe shortness of breath that does not respond to bronchodilators treatments
Changes in skin color to bluish or grayish tone
Increasing confusion

There are areas or times of increased risk to this process for which the nurse should be aware. One such instance would be when the patient is seen by a clinic or for a follow-up appointment. If there is a change in the patient health status or if the patient is transferred to an alternative level of care, there is increased risk that medication reconciliation will not occur, and red flags should be placed at these points. The goal is always to communicate to the next provider an up-to-date, complete, accurate list of prescription and nonprescription medication list. At each of these red flag areas, the home health nurse should verify that the family and the patient understand any changes to the medications. If there are questions, they should be answered. The new medications should be reviewed and instruction provided regarding the purpose and how it pertains to and affects the patient's health.

Another red flag would be several treating providers (e.g., the patient sees a nephrologist, cardiologist and internal medicine physician). It is important in this instance to pick the "captain of the ship," which is often the referring physician who oversees the medications and reviews and approves any changes. However, situations arise where an underlying condition is out of control; therefore, the primary physician becomes the one who is likely to change the medications because of the effect they are having. For example, a physician treating a patient in liver failure may request notification of any new medications the patient is given and require his approval of the medication prior to administration because of the effect it might have on the liver disease.

Other red flag issues to consider include:

More than five medications, which can place a patient at high risk

Patients who ask, "When was I supposed to take that medication?"

Pill bubble packs that are punched out irregularly

Pills left all over the home, such as in the kitchen, bathroom and bedroom, are a signal that medications are likely being taken at random times

Nonprescription medications that the patient takes, which he or she may neglect to start taking again after discharge from the hospital

The patient does not know where his or her medications are and how often they are to be taken

Hospital visits that could be avoided had medications been taken at the correct time or through the proper administration method

The patient accidentally overdosed in the past

The patient takes high-risk medications (i.e., medications that sound the same as other drugs or the dosage is particularly confusing)

These are several of the more common or obvious red flags. There are probably many more with which you are familiar. What is important is that the home health nurse identifies those that are specific to the patient in order to be alert to potential problems so he or she will be aware of when to contact the physician if problems arise. Elevated blood pressure, elevated pulse, difficulty breathing, symptoms of wound infection or digoxin toxicity, and a bladder infection that affects patients with a Foley catheter are some examples.

Engage the patient in self-care

Engaging the patient in his or her care can be achieved in a number of ways. For example:

Provide the list of medications you develop and give it to the patient to review for accuracy or completeness.

Ask open-ended questions during the interview process, which will help collect the patient's information.

Have the patient show you all of the bottles of medications he or she takes, including any daily vitamins.

Ask the patient for the telephone number of his or her pharmacy and then place it in an easy access area, perhaps on the refrigerator or at the bedside.

Provide the patient with little-known information about his or her medications. This always seems to stimulate attention. In addition, stories about the medication help too and may also serve as a memory aid.

Encourage the patient to ask questions, especially if new medications are ordered or if the dosage is changed on a medication.

Have the patient keep a daily log of when medications were taken. This provides the additional benefit of maintaining an accurate medication list.

Provide the patient with handouts discussing his or her disease and the medications used to combat it.

Patients with diabetes, heart disease and respiratory problems are at a high risk for readmissions and remain a target population for intense monitoring of health status, self-care skill and self-care knowledge. Any discharged patient with four or five comorbid conditions requires a focused approach with specified care guidelines, triggers for readmission and patient-centered goals.

Use plain and simple terms to help the patient understand and feel more in control of his or her care.

Use words that the patient can pronounce.

Create a supportive atmosphere for the patient so he or she feels at ease in stating what is not understood or what is confusing.

A patient may feel more engaged during treatment if there is an easy and comfortable way for him or her to report discrepancies or errors.

Be sure to include potential risk to patients in your care plan and then list evaluation methods that are quick and easy for the other healthcare team members to follow.

Ensure timely physician follow-ups

Schedule a physician follow-up visit after a hospitalization, as the physician directs in the discharge orders. If there is no mention of when to schedule a follow-up appointment in the discharge note, make certain to ask the physician about a follow-up visit when the initial interview with the patient is completed. This can occur when you contact the physician to resolve medication questions or clarify other issues. The initial follow-up visit should never be more than two weeks post-discharge.

There are many things the home health nurse can do to facilitate the physician follow-up and make the visit more beneficial to the patient and doctor. A few suggestions include:

Keep a medical appointment log up to date.

Use a large calendar for appointment dates. Place it in an area where all can see.

Stay organized. Help the patient form questions and write them down. Have the patient write brief questions regarding his or her disease or the disease process. This increases communication between the patient and the physician.

Place the insurance card in the patient's folder to bring to the physician.

Be certain the current list of medications is with the patient but also have the patient bring all medication bottles, as well as the box with the scheduled pills in it. Include both prescription and nonprescription medications, so if there are questions about medications, the physician has them readily available to look at.

Identify adverse signs and symptoms that should be looked for and under what circumstances the physician should be called.

Find out from the physician what to do in an emergency and when office hours are.

Make certain the patient has transportation to the follow-up visit.

When patients have this information, it is easier for them to feel relaxed, decreases their anxiety and enables them to become a more effective contributor to their ongoing medical treatment.

This also ensures that the physician has as much information as possible to thoroughly evaluate the health status of the patient during the office visit.

Medication compliance, safety, education and effects

Older adults frequently fall victim to medication nonadherence. There are many reasons for this, ranging from simple to complex. From consciously skipping medications due to financial concerns or simply forgetting to properly take multiple medications, education is key.

A system of checks and balances should be in place, as the older adult can be especially vulnerable to the unintentional consequences of polypharmacy, missed doses and accidental "adjustments" that may occur. The therapeutic range of many lifesaving medications may be very narrow, and monitoring by the home health staff should be frequent and thorough.

Keep tabs on medication habit and compliance. Be sure to:

Ask the patient whether he or she is taking their medications. If not, ask open-ended questions regarding why this is happening (e.g., do you feel the medication simply is not working?).

Document the patient's cognitive level, response to teaching, support system and changes in conditions (this should be ongoing).

Take action if you notice subtle changes in health, such as:
- Increased bruising
- Bleeding gums (indicating increased coagulation)
- Slight shortness of breath or pedal edema (indicating missed diuretics)

Ask the patient to identify specific pills and reasons for taking them.

Check to make sure the medications in the pill bottle are going down.

Perform a simple physical assessment - is there weight gain or elevated blood sugars? Elevated blood pressures, headache, pain these symptoms may dissipate if the patient is taking his or her medications.

Help the patient remember medication by organizing a pill box.

If there are problems with the purchase of medications, refer the patient to a social worker in order to obtain Medicare Part D coverage or other insurance coverage. Consult with the pharmacist on lower-cost medications that provide the same result. Ask the physician if he or she has samples.

Continue to monitor for adherence and medication side effects that could be present and may be keeping the patient from compliance.

Monitor laboratory work for the prescribed medications.

Assemble an accurate list of all medications

Request that the patient write down all medications he or she is taking, including over-the-counter drugs and nonprescribed medications. Include the name of the doctor who prescribed the medications and what the medication is taken for (this can be done in layman's terms [i.e., water pill, high blood pressure]). Even writing "I don't know" is acceptable so that the physician or pharmacist can then explain why the medication is prescribed. If the patient knows that he or she have a side effect to the medication, it is a good time to write that down so it is available at the next follow-up visit with the physician or the pharmacist.

Tell patients to keep the medication list with them at all times. Take it to physician visits and always on visits to the hospital.

Explain to the patient the importance of updating the list when medications change or when the physician changes the dose, stops a medication or tells the patient to discontinue taking it.

Help the patient manage medications themselves

In determining the patient's ability to manage his or her medications, adhere to the following steps:

Encourage the patient to learn about their medications. What is the name of the drug? What does it do? How do you take this medication? How does it make you feel? Are there special instructions? Do you have to take it with food?

Screen for adverse or drug interactions. If adverse drug interactions are identified, report them to the prescribing provider and the pharmacist.

If the medical diagnosis is present, provide the primary and the secondary diagnosis from the prescribing provider.

If the patient is older than 65, use BEERS criteria or high-risk criteria for evaluation.

Instruct the patient to never take someone else's medication, especially prescription medication.

Explain that the medication is like a dangerous chemical that should only be taken with a doctor's instruction.

Use only the cup or syringe supplied with the medication. Never put insulin in a noninsulin syringe.

Choose a primary pharmacy where a medication review can be done and where medications can be delivered to the patient's home, if possible. Fill the medications at the same pharmacy and choose to visit only that pharmacy for the patient's needs.

Instruct patients to always tell the physician or pharmacist when he or she is taking an herbal medication, even if it says "all natural" on the bottle or box.

Be certain to verify everything with a prescription, if necessary.

Tell the patient to call the physician's office or pharmacy with any questions about medications being taken or that may be needed.

If the patient requires surgery, he or she should ask about medication consumption prior to the surgery.

Prior to leaving the hospital, patients should ask for a list of the medications that should be taken at home, especially blood thinners or medications that affect bleeding.

Finally, if the medication is supposed to be treating headaches but the headaches continue, notify the physician or pharmacist and discuss with the health care team regarding a change in medication or perhaps a change in dose. There are several tools, such as the home health tracking sheet, that will assist in monitoring medication adherence and side effects. However, it is important to use the one that works best in your system. This is paramount to its effectiveness.

Enroll the family caregiver or advocate

Effective disease control requires that the patient and the caregiver are active participants in the patient's care. The role of the family caregiver varies according to the individual's ability to provide certain types of services.

Taking time for respite care for the caregiver and assisting the caregiver in learning when to contact the physician are paramount measures to preserve the integrity of the caregiver's ability. Education and communication provide the caregiver with a better understanding of the disease and the disease process. The knowledge empowers the caregiver to feel supported in decisions.

Teaching the signs and symptoms of the disease and the disease process and the measures to take should there be a complication will help and decrease the frivolous rehospitalizations in chronic care patients.

Determine a primary care coordinator

Fewer than half of the patients with chronic illness and the targeted high-risk illnesses of HIV/AIDS, mental health, substance abuse, chronic heart failure, chronic obstructive pulmonary disease and diabetes have primary care physicians who are dedicated to their care. Which physician or pharmacist will provide medical decisions and steer the ship through rough waters? Deciding who the primary care provider is, providing the patient with a contact number and scheduling the follow-up visit after hospitalization is critical to keeping the patient out of the hospital with an unnecessary visit.

Connect the physician dots

When there are two or more physicians treating a patient, each should be made aware of what the other is doing. This is a daunting task. However, there are ways to make this step less complicated. A physician list with the phone numbers and contact information should be available. The name of the referring physician should also be readily available to answer any questions relating to the patient or the patient's medication regime. Typically, contacting the physician who prescribed the medication is ideal, but the pharmacist can be of best service when there are three or more medications involved.

We know the average chronic care patient ingests 10 to 12 medications daily. Making sure that the pharmacist and physicians possess a current medication sheet helps bridge the communication gap and thus eases stress on the treating provider and the patient. Requesting the pharmacist provide a medication therapeutic review will assist the physicians and reassure them that these medications can be administered together without harm.

Patient education

Educate patients and families to make them aware of a high-risk situation if that is what is present. Provide them with the signs and symptoms of complications and provide them with physician's orders that clearly state when to call and the parameters to follow for complications in the patient's disease or illness. For example, in cases of chronic heart failure, a daily weight gain of 5 pounds may cause a physician or pharmacist to order to take an extra furosemide dose or draw digoxin levels. Create an environment for the patient with chronic illness that is supportive and reassuring so anxiety is decreased (knowing what to do in an emergency is empowering to the patient).

Source:

Essential In-Services for Home Health, 2023

Chapter 45 - Readmissions (p. 517-530)