Website spotlight: Prevent readmissions with nurse intervention

Nurse Leader Insider, October 3, 2011

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Changing reimbursement incentives are forcing hospitals to focus on preventing readmissions. However, hospitals are stymied when patients fail to take the medications that may keep them out of hospital.

Hospitals routinely have nurses follow up with discharged patients by telephone to monitor their recovery and ask about medications, but even that can be problematic.

"We couldn't tell on the telephone that they were not taking medications," says Linda L. Costa, RN, nurse researcher at The Johns Hopkins Hospital, and assistant professor at Johns Hopkins University School of Nursing.

Adding a home visit from a nurse soon after discharge may provide a beneficial and cost-effective option to keep the most complex patients out of the hospital. A study by an interdisciplinary research team that included two nurses and a pharmacist based at The Johns Hopkins Hospital has shown promise for increasing nursing involvement and helping patients stay on track and out of the hospital.

The study, funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative, took a group of chronically ill patients taking multiple medications and examined whether a simple, early intervention could make a difference in the patients' post-hospital progress and prevent readmissions. The study sent nurses on home visits to discuss medications and solve problems that prevented patients from sticking to their regimens.

Costa, the lead researcher, says the study was launched because nurses were getting calls from patients post discharge to clarify medication orders. Costa says many patients with chronic illnesses are faced with complicated medication regimens that they may not understand, have prescriptions that need to be filled, and are frequently left wondering what to do about prescriptions they had been taking before hospitalization.

"We had to go to the home and see it," Costa says. "It was the only reliable way to really know what medication management is."

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