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Mar 1, 2021 · Numerous care transition processes reduce readmissions in clinical trials. The objective of this study was to examine the relationship between the number of evidence-based transitional care processes used and the risk standardized readmission rate (RSRR). Methods. Design: Mixed method, multi-stepped observational study.
- Jacqueline Pugh, Lauren S. Penney, Polly H. Noël, Sean Neller, Michael Mader, Erin P. Finley, Holly ...
- 2021
- A Pilot Quality Improvement Project
- Local Context for Delivery of the Intervention in the Health Care Setting
- Plan for Assessment of Completeness and Accuracy of Data
- Ethical Considerations
- Contextual Elements That Interacted With the Intervention
- Limitations
Kate Shade, PhD, RN, Paulina Hidalgo, MSN, RN, Manuel Arteaga, MSN, RN, Janet Rowland, EdD, MSN, RN-BC, ACM-RN, and Winnie Huang, MSN, RN, PHN
Case managers developed this QI project as part of an ongoing health care improvement initiative to reduce readmissions. As part of this broader health care improvement initiative, the case managers approached the university about piloting the proj-ect as an academic–clinical partnership. Students who were completing their final semester for a mas-...
The authors created a plan to ensure that the data obtained were complete and accurate. The team used a secured, password-protected shared drive to store all data. Information was accessible to NCM students and clinical partners. Patient data included age, gender, admission date, primary admission diagnosis, number of chronic conditions, and number...
The data collected were limited but did include criti-cal information. Direct patient identifiers were shared only between students and case managers. The data set included de-identified patient characteristics such as age and gender and some personal health infor-mation such as admission dates and diagnoses. The health care institution determined ...
A few contextual factors affected delivery of the intervention. The NCM students spent 4 weeks orienting to the health care system and learning about the service lines and case management con-tacts designed to reduce readmissions. Because of the NCM students’ class schedules, initial outreach and follow-up were not always completed in a timely mann...
This study had some limitations. The team intended to obtain preliminary evidence of the feasibility and effectiveness of ICM services delivered by nursing stu-dents to reduce readmissions for at-risk patients using a pre-/postdesign without a randomized controlled group. Although we compared the readmission rates of program participants and nonpar...
Jun 7, 2024 · By addressing the root causes of readmissions and implementing strategies that focus on patient education, care coordination, and addressing social determinants of health, healthcare institutions can make significant strides in reducing readmissions and improving patient outcomes.
Nurse case managers evaluated each readmission case and, in alignment with patient perspectives, identified system factors most of the time (Smeraglio et al., 2019). When providers and other members of the care team are ‘dinged’ for patient outcomes, they may be more likely to assign blame for readmission to patients.
- Kathryn Taylor, Patricia M. Davidson
- 2021
Jan 18, 2024 · Multidisciplinary communication approaches led by emergency medicine can help reduce readmissions significantly. Adopting a structured communication workflow can enhance co-managing patients with a high risk of readmission between the emergency department and hospital medicine teams.
The primary aim of this study was to pilot an intensive case management (ICM) intervention to reduce 30-day hospital readmissions. A secondary aim was to obtain patient- and caregiver-reported reasons for readmission.
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Staff physicians, residents and interns correctly predicted patients who would return to hospital within 30 days with a C statistic of around 0.58 (considerably below the typical target for acceptable discrimination of at least 0.7). Nurses and case managers performed little better than chance (with C statistics of …
