Rehospitalizations Are a Continuum Problem, Speaker Says

​Rehospitalizations are not a facility problem but "really a continuum problem," said Peg M. Bradke, RN, M.A., director of heart care services at St. Luke's Hospital (Cedar Rapids, Iowa) and faculty for the Institute for Healthcare Improvement's (IHI) State Action on Avoidable Rehospitalizations (STAAR) initiative, during "IHI's Approach to Reducing Avoidable Rehospitalization," presented Saturday, September 22, 2012, at the National Association for Healthcare Quality's annual conference in Tampa. The STAAR initiative focuses on four key changes for hospitals, skilled nursing facilities, and home care: comprehensively assessing postdischarge needs, teaching effectively and facilitating learning, ensuring postdischarge care and follow-up, and designing effective handovers. A central element is the cross-continuum team. "You've got to put that picture all together," said Bradke. Another is the diagnostic review, in which the cross-continuum team reviews the last five hospital readmissions to understand why the person was readmitted. It's important to include interviews with the patient or resident in diagnostic reviews because rehospitalizations often stem from a social, family, or financial issue, Bradke noted. Ensuring patient or resident understanding is another critical issue.