Reducing Hospital Readmissions after Short-Stay Patients Go Home

January 17, 2014 | Aging Services Risk, Quality, & Safety Guidance

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​“A wide variety of traditional nursing home approaches to care need to be reexamined if short-stay patients are to be properly prepared for return home,” writes columnist Jeffrey Nichols, M.D., in the March 2013 Caring for the Ages in response to a question from a nursing home whose main referral hospital was dissatisfied with its readmission rate. Although the nursing home itself returned few patients to the hospital, many were readmitted to the hospital after discharge home. According to Nichols, changes should include new approaches to evaluation of patient status and care goals, patient and family education, and communication with postdischarge providers; simplification of medication regimens; and elimination of procedures and technologies that the patient could not effectively use at home. Discharge summaries must be complete and part of an integrated process; it is not enough to hand the patient a list of medications and equipment and contact information for a home care agency. The summary should describe events that happened during the stay, current patient status, and a comprehensive discharge plan of care.

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