Another Look at Readmissions
Katie Westman, RN, CNSUnited Hospital
Caring for the person…in context
Reason for Readmissions
O Progression of diseaseO Unrelated to original hospitalizationO Preventables
O Medications, medications, medicationsO Lifestyle – smoking, for exampleO Access – primary knowledgeable
about disease state, regular testing, healthy foods, exercise, patient education, social support, finances
TacticsO Better assessments in the acute care setting
O Identifying “hidden” needs (medication adherence, cognitive abilities, mental health issues, literacy)
O Cognitive assessmentsO Transition conferences
O Involving support system
O Comprehensive discharge planningO Redesigning the discharge processO Simplifying and communicatingO Involving patients and support systemsO Appropriate placement
Questions to Think About Before the ConferenceHere are some things to think about as you plan to transition from the hospital:O1. Who usually helps you with your everyday activities at home?
O Food? Medicine? ADLs?O How would you contact that person?
O2. Who helps you make decisions about your health care?O3. Whom do you call when you have questions or concerns about your health?
O How do you get to your health care appointments?
O4. Do you have any concerns about how you will pay for your health care needs?
O Transition care supportO Transition coaches, APRNs,
community supportO Transition communications
O Allina transition conferencesO http://www.hospitalmedicine.org/
ResourceRoomRedesign/RR_CareTransitions/PDFs/PASS.pdf
RARE Campaign
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