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Reduction in Readmissions

The importance of follow-up in providing better, more compassionate care

Nurses strive to provide empathic, compassionate care. However, this can be near impossible when their environment is not conducive to helping them work efficiently as a result of high readmission rates. Not only can unnecessary patient readmissions increase workloads, but they can also generate a sense of "Did we fail the patient somehow?" among nurses.

It becomes clear that reducing unnecessary patient revisits is an important way not just to improve costs and quality of care, but also to give nurses the environment needed to practice the patient-centered, empathic care they endeavor to provide.

As illustrated by CHI St. Vincent in Little Rock, Ark., increasing contact with surgical patients and tracking them outside the facility helps hospitals more effectively address the causes and barriers that lead to readmissions. This positively impacts the working conditions and morale of the nursing staff.

Unnecessary Hospital Readmissions
The Joint Academy Program at CHI St. Vincent discovered there were two main types of causes that can lead to patients revisiting the hospital for the same problem: direct and indirect. Indirect causes include insufficient financial resources, lack of transportation, and lack of social support. Such factors can cause patients to be unable to afford prescription renewals, physical therapy, or other follow-up treatments. They can also keep patients from being able to get to therapy and follow-up appointments, leading to deterioration in their condition and need for readmitting to the hospital.

Unnecessary readmissions can have significant impact on hospital care and resources. For one, they count against a hospital's HCAHPS1 and other measures of care quality. For another, they result in excessive costs of care and treatment, and they can divert nursing resources from patients who really need the care. In addition, they can place extra stress on nursing staff and lead to compassion fatigue.2

As a result, many hospitals within the Little Rock area strive to track and address the issues that lead to excessive readmissions. Most hospitals, however, look only inside "their own four walls" for evidence that someone has had to return for additional treatment. They also generally limit follow-up patient calls to one at 48 hours post-surgery.

Common as it is, however, this approach has several shortcomings. For one, it doesn't fully reveal the person inside the patient or seek to uncover the big picture as to why the patient is being readmitted. This can lead to a lack of ever solving the problem and rather applying a quick fix to a long-term issue. It also doesn't foster empathic care by giving nurses the tools to understand the patient's story, goals, and health on a personal level.

Recognizing that a better approach was needed, the Joint Academy Program at CHI St. Vincent embarked on a new plan to reduce hospital patient readmissions through looking at the big picture impacting each patient's journey. Our program increased and streamlined its pre-surgical patient contacts and postsurgical follow-up calls. Specifically, we instituted pre-surgical and post-surgical 24-hour, 48-hour, 10-day, 30-day, 90-day, and 120-day follow-up calls. In addition to employing workflow solutions to better track each patient, our goal with the new system was to apply an empathic approach to care by getting to know the person inside every patient so we could uncover external barriers to care and potential complications.

SEE ALSO: The Real Cost of Readmissions

To further address the full reason for a patient returning, one must look at the financial and operational shortcomings of this approach. For example, it is often not revealed that a readmission has been tallied against hospitals for patients who need to visit another provider for treatment until weeks or months following the visit. In addition, many complaints such as swelling and bruising don't surface until 7-10 days or longer post-surgery. Finally, it doesn't proactively address many of the indirect causes of readmissions, such as the inability to pay for refills, lack of transportation, and lack of social support that can ultimately lead to a patient's inability to follow treatment plans. These impacts, in turn, can contribute to higher levels of nursing stress, burnout, decline in morale, and other consequences that affect the quality of care provided by a hospital's nursing team.

Concrete, Emotional Results
The results of this method greatly exceeded our expectations. Not only did the Joint Academy Program benefit from a dramatic reduction in patient readmissions - plummeting from 24 percent to at times less than 4 percent - but we also experienced improved nurse staffing ratios and better morale as a result of being able to offer empathic care.

In addition to the improvements nurses have noticed, the increased contact also benefits patients. For example, there was a knee-replacement patient whose husband was in a wheelchair and didn't have any other social support to rely on once she got home from the hospital. Knowing she didn't have all of the support at home that she needed, we were able to make a 24-hour follow-up call rather than the standard 48-hour call. This quick follow-up led us to discover the patient needed immediate attention for health concerns. We were able to have the patient admitted to St. Vincent's under the care of her orthopaedic surgeon. During that time, the surgeon and the inpatient team were able to review her needs and barriers. Her surgeon decided the best plan of care was for her to discharge to a skilled nursing facility so she could receive a higher level of healthcare.

Excessive hospital readmissions can be costly and negatively impact quality scores and nursing resources. But, most importantly, not seeing the full picture to a patient's health can stand in the way of delivering the empathic care nurses strive to provide. Unlike the "standard operating procedure" followed by most hospitals, far more hospital readmissions can be reduced by looking outside the facility's own four walls, improving the way they track each patient's journey and revealing the real reasons for excessive patient visits.

Indeed, these solutions not only help cut costs and improve the quality of care, they give nurses the tools needed to practice patient-centered, empathic care that fuels our passion for what we do.

1. Press Ganey Associates, Inc. The Relationship Between HCAHPS Performance And Readmission Penalties. South Bend, IN; 2012.
2. Dempsey C, Wojciechowski S, McConville E, Drain M. Reducing patient suffering through compassionate connected care. The Journal of Nursing Administration. 2014; 44(10):517-524.

Labray Merkel is care coordinator at CHI St. Vincent in Little Rock, Ark.

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