Another Look at Readmissions

1. Another Look at Readmissions Katie Westman, RN, CNS United Hospital

2. Caring for the person…in context

3. Reason for Readmissions • Progression of disease • Unrelated to original hospitalization • Preventables • Medications, medications, medications • Lifestyle – smoking, for example • Access – primary knowledgeable about disease state, regular testing, healthy foods, exercise, patient education, social support, finances

4. Tactics • Better assessments in the acute care setting • Identifying “hidden” needs (medication adherence, cognitive abilities, mental health issues, literacy) • Cognitive assessments • Transition conferences • Involving support system • Comprehensive discharge planning • Redesigning the discharge process • Simplifying and communicating • Involving patients and support systems • Appropriate placement

6. Questions to Think About Before the Conference Here are some things to think about as you plan to transition from the hospital: • 1. Who usually helps you with your everyday activities at home? • Food? Medicine? ADLs? • How would you contact that person? • 2. Who helps you make decisions about your health care? • 3. Whom do you call when you have questions or concerns about your health? • How do you get to your health care appointments? • 4. Do you have any concerns about how you will pay for your health care needs?

7. Transition care support • Transition coaches, APRNs, community support • Transition communications • Allina transition conferences • http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/PASS.pdf

8. RARE Campaign