A Targeted Discharge Planning for High-Risk Readmissions: Focus on Patients and Caregivers

Eunice Park-Clinton; Susan Renda; Flint Wang

doi:10.1097/NCM.0000000000000591

A Targeted Discharge Planning for High-Risk Readmissions: Focus on Patients and Caregivers

Prof Case Manag. 2023 Mar-Apr;28(2):60-73. doi: 10.1097/NCM.0000000000000591.

Authors

Eunice Park-Clinton^{1

2

3}, Susan Renda^{1

2

3}, Flint Wang^{1

2

3}

Affiliations

¹ Eunice Park-Clinton, DNP, MSN, MBE, RN , has been a case manager for 12 years and teaches nursing students. Her passion for safe discharge earned her case manager of the year at the hospital she works. Her endeavors are to improve the quality of life of the elderly and their awareness of advance directives.
² Susan Renda, DNP, ANP-BC, CDCES, FNAP, FAAN , is an assistant professor and associate director of the DNP Advanced Practice Program at Johns Hopkins School of Nursing. She also maintains a faculty practice as a nurse practitioner in the Hopkins Diabetes Center, where she cares for people with diabetes and increases access to patient education.
³ Flint Wang, MD, is an assistant professor of clinical medicine, and hospitalist physician at the University of Pennsylvania. He is the director of Health Information Technology curriculum for the Perelman School of Medicine at Penn, and was a former medical director for the hospitalist inpatient service.

PMID: 36662660
DOI: 10.1097/NCM.0000000000000591

Abstract

Purpose of study: Racial and ethnic minorities with socioeconomic disadvantages are vulnerable to 30-day hospital readmissions. A 16-week quality improvement (QI) project aimed to decrease readmissions of the vulnerable patient populations through tailored discharge planning. The project evaluated the effectiveness of using a 25-item checklist to increase patients' and caregivers' health knowledge, skills, and willingness for self-care and decrease readmissions.

Primary practice setting: The project took place in an inner-city teaching hospital in the Mid-Atlantic region.

Methodology and participants: A casual comparative design compared readmissions of the before-intervention group (May 1-July 31, 2021) and the after-intervention group (August 1-October 31, 2021). A pre- and postintervention design evaluated the effectiveness of a 25-item checklist by analyzing the differences of Patient Activation Measure (PAM) pre- and postintervention survey scores and levels in the after-intervention group. Participants were General Medicine Unit patients 18 years or older who had Medicare Fee-for-Service, resided in 10 zip codes near the hospital, and were discharged home.

Results: Of 30 patients who received the intervention, one patient was readmitted compared with 11 readmissions from 58 patients who did not receive the intervention. The readmission rate was decreased from 19% to 4% during the 16-week project: 11 (19%) versus 1 (4%), p = .038. After receiving the intervention, patients' PAM scores were increased by 8.55, t(22) = 2.67, p < .014. Three patients had a lower postintervention survey level, whereas 12 patients obtained a higher postintervention survey level (p = .01). The increase in scores and levels supported that the intervention effectively improved patients' self-management knowledge, skill, and willingness for self-care.

Implications for case management practice: The QI project showed that the hospital could partner with patients at high risk for readmission and their caregivers. Accurate evaluation of patients' health knowledge, skills, and willingness for self-care was essential for sufficient discharge planning. Tailored use of the checklist improved patients' self-activation and functionally facilitated patients' and caregivers' care needs and capabilities. The checklist was statistically and clinically effective in decreasing 30-day hospital readmissions of vulnerable patient populations.

MeSH terms

Aged
Caregivers
Humans
Medicare
Patient Discharge*
Patient Readmission*
Self Care
United States