The document discusses decreasing hospital readmissions in the elderly population. It presents barriers to readmission like functional limitations, social isolation, and poverty. It proposes interventions like comprehensive admission assessments, multidisciplinary care, discharge planning, phone follow-ups, and exercise programs. Studies showed readmission rates decreased to 3% after 3 days and 14% after 30 days with these interventions, compared to 22% after 30 days with exercise and follow-up calls alone. Recognizing patient values, identifying risks, and addressing barriers can help lower elderly readmissions.

1. Decreasing Readmissions
at Discharge
Presented by: Courtney Norris, Nicholas Weida and Brooke
Wilsman

2. Background
How we formulated the PICO question
Good Samaritan Hospital in Lebanon, PA
Problems with hospital readmissions
Currently uses the teach-back method
http://www.ema.net/the-good-samaritan-hospital-.html

3. PICO Question
In the elderly population, will identifying barriers to readmission coupled with
creating interventions to combat the barriers decrease hospital readmissions as
compared with the standard teach-back method?

4. Learning Objectives
1. The learner will indicate three concerns for the discharge nurse to discuss over the phone with the
recently discharged patient.
2. The learner will identify key assessment techniques that should be included in the admission of the
geriatric client in the hospital.
3. The learner will uncover what aspects of care the geriatric population wish to include in their own
discharge plan.
4. The learner will be able to identify risk factors and barriers that can cause hospital readmission.

5. Elderly Client Concerns at Discharge
The elderly like to be involved with discussing:
Time of discharge
When the patient goes home
Community Health
Dependency on public careers
Fear of not receiving accurate care
Not getting medical follow-up
Practical Matters
Housekeeping
(Foss and Askautrud, 2010)
http://alzheimershomecarenj.com/home-care-after-hospitalization-
understand-the-role-of-the-hospital-discharge-planner/

6. Comparison of Values in Recently Discharged Elderly
PatientsValues differ from each perspective
Elderly values:
Personal Care - Caregiver options
Mental Ability - carrying out everyday activities
Autonomy
Relatives of the elderly values:
Safety and security
Caregiver burden
Psychological well-being
(Denson, Winefield, and Beilby, 2013)
https://www.burnaby.ca/Our-City-Hall/City-Departments/Engineering/Safety-and-
Security.html

7. Teach Back Method Better Than Discharge
Instructions?Evidence says no
There was no significant difference between:
Medication adherence
Therapeutic alliance
Patient’s experience
Readmissions
Many studies continue to articulate inconsistent results
(Hyrkas and Wiggins, 2014)
http://www.teachbacktraining.org/

8. Risk Factors for Hospital Readmission
● Certain comorbidities cause an increased risk for hospital readmission
○ Hypertension
○ Diabetes mellitus
○ Chronic obstructive pulmonary disease
○ Congestive heart failure
○ Coronary artery disease
○ Dementia
○ Stroke
○ Chronic kidney disease
(Bogaisky and Dezieck, 2015)
https://www.dred.com/signs-and-symptoms-of-
hypertension.jpg
https://gigaom.com/wp-
content/uploads/sites/1/2014/01/diabetesmeter.jpg

9. Who is at risk?
Nursing home residents have been found to be more at risk for being readmitted to the hospital
than the elderly population that live independently in the community
Often have higher levels of comorbidities and a lower functional status when compared to the elderly
that live independently
More likely to be readmitted from complications of congestive heart failure and dementia
Have higher rates of diabetes, coronary artery disease, congestive heart failure, end-stage renal disease,
and dementia than the elderly that live within the community
More likely to be nonverbal during their hospital stay
Live in a unique environment with access to health care providers daily
Have greater risk of mortality during their hospital stay than those that live in the community
(Bogaisky and Dezieck, 2015) http://f.tqn.com/y/seniorhealth/1/W/b/s/467305389
.jpg

10. What about the community-dwelling elderly?
● Post-discharge readmissions are often related to fragmented care and
adverse drug events
● Traditional discharge instructions often overlook the
functional gaps related to these patients due to
living independently
● Many elderly adults living within the community
have barriers or “missing pieces” that enable them from
properly caring for themselves once they leave the hospital
(Greysen et al, 2014)
http://blog.nolo.com/immigration/files/2014/02/puzzle-w-
missing-pieces.jpg

11. Functional Limitations
Mobility and instrumental activities of daily living
Shopping, cooking, and cleaning were found to be some of the main difficulties faced at home
Muscles become atrophied after being immobile at the hospital for an extended period of time
Function within the home
Many elderly patients have reported to forgetting the obstacles
in the home that can delay care
Difficulty with going out of the home
Depletes the needed reserves of recovering
Using more energy(Greysen et al, 2014)
http://growingleaders.com/blog/wp-content/uploads/2010/07
/muscle-atrophy.jpg

12. Social Isolation
Unable to interact
Often stay home due to lack of energy and strength from
hospital stay
Support from others slowly diminish
Transportation difficulties
Coordinating schedules became too difficult
Lack of social support
From progressive illness and loss in functional abilities
Loss of connection with friends(Greysen et al, 2014)
http://www.alternet.org/files/styles/story_image/public/story_images/social_isolation.jpg

13. Challenges from Poverty
Certain conditions or diseases can cause someone to lose their job and even
their home
Depending on the area where the patient resides, it can worsen their illness
from contributing factors in the community
Physical features of home and community can threaten their well-being
Living in smaller environments with more people often make the susceptibility of
contracting an illness more likely
(Greysen et al, 2014)
http://i.dailymail.co.uk/i/pix/20
13/07/22/article-2372951-
05BE14010000044D-
765_634x420.jpg

14. Implementing Interventions at Admission
Hospitalists trained to perform comprehensive admitting assessment tools
Tool includes
Geriatric History and Physical Form
Fall Risk Scale
Caregiver Capacity
Healthcare Proxy
Home Setup Evaluation Tool
Practices r/t Home Medication Regimen
https://www.google.com/search?hl=en&site=imghp&tbm=isch
&source=hp&biw=1366&bih=673&q=doctors+doing+admissio
n+assessments&oq=doctors+doing+admission+assessments
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_BpSGNXa52ncM%3A
(Courtney et al, 2009)

15. Implementing Interventions during Hospitalization
Incorporate daily appointments with Physical Therapist to provide various
exercise routines
Multi-disciplinary Team Coordination during hospital stay
Physical Therapy
Occupational Therapy
Nutritionist
Social Work
Home Care Nursing PRN
Recommendations based on perspectives after evaluation
(Dehia et al 2009)
https://www.google.com/search?hl=en&site=
imghp&tbm=isch&source=hp&biw=1366&bih
=673&q=multiple+health+care+professionals
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4M%3A

16. Implementing Interventions at Discharge
Discharge includes the Discharge Planning Nurse, Discharge Planning
Hospitalist, and patient
All collaborative recommendations from health care professionals discussed
Written discharge instructions with large font and simple language
Easy-to-navigate grid on medications
Exercise routine provided by PT
Consult for Home Care Nurse implemented
(Dedhia et al, 2009)
https://www.google.com/search?hl=en&site=imghp&tbm=i
sch&source=hp&biw=1366&bih=673&q=multiple+health+
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17. Implementing Interventions after Discharge
Follow-Up Phone Conversations with patient and Discharge Planning Nurse
48 hours after initial discharge along with Home Care Nurse visit
Weekly phone calls for 4 weeks
Monthly phone calls for 5 months
Nurse to Patient discussions include
Transitional Concerns
Assessment of further home visits with Public Health Nurse
Accessibility of resources
Medication knowledge
(Courtney et al, 2009)
https://www.google.com/search
?hl=en&site=imghp&tbm=isch&source=hp&biw=1366&bih=673&q=multi
ple+health+care+professionals&oq=multiple+health+care+professionals
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&imgrc=bn15z_Ze8UwRoM%3A

18. Rates of Readmission Statistics
Only 3% of patients were readmitted back to the hospital within 3 days
after the comprehensive admission assessment and discharge plan was
implemented (Dedhia et al, 2009)
Only 14% of patients were readmitted back to the hospital within 30 days
after the comprehensive admission assessment and discharge plan was
implemented (Dedhia et al, 2009)
https://www.google.com/search?hl=en&site
=imghp&tbm=isch&source=hp&biw=1366&
bih=673&q=multiple+health+care+professio
nals&oq=multiple+health+care+professional
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ch&q=readmission+&imgrc=DRzp8fCH0tTH
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19. Rates of Readmission Statistics
Only 22% of patients were readmitted back to the hospital within 30 days
after the exercise and follow-up phone call regimen was implemented
(Courtney et al, 2009)
67% of patients reported a higher quality of life after the exercise program and
follow-up phone call regimen was implemented (Courtney et al, 2009)
https://www.google.com/search?hl=en&sit
e=imghp&tbm=isch&source=hp&biw=1366
&bih=673&q=multiple+health+care+profes
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tbm=isch&q=readmission+&imgrc=gxzxDw
RXcnkFPM%3A

20. Recommendations
Recognize that many elderly have different values as healthcare providers
Be aware that teach-back is as effective as simply telling them information
Implement multiple healthcare professionals with discharge
Allow interdisciplinary communication to occur with every patient
Work with case management to evaluate needs for
Home care nursing
Physical therapy
Occupational therapy

21. Recommendations Continued
Assess patients for barriers that may affect their ability to care for themselves at
home
Identify who is at risk for being readmitted
Know the functional limitations of your patient
Understand the social and financial aspects of their life to identify any other
missing pieces that may not be physically evident

22. References
Bogaisky, M., & Dezieck, L. (2015). Early hospital readmission of nursing home residents and community-dwelling elderly adults
discharged from the geriatrics service of an urban teaching hospital: Patterns and risk factors. Journal of the American Geriatrics
Society, 63(3), 548-552 5p. http://dx.doi.org/10.1111/jgs.13317
Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer emergency readmissions and better
quality of life for older adults at risk of hospital readmission: A randomized controlled trial to determine the effectiveness of a 24-week
exercise and telephone follow-up program. Journal of the American Geriatrics Society, 57(3), 395-402.
http://dx.doi.org/10.1111/j.1532-5415.2009.02138
Dedhia, P., Kravet, S., Bulger, J., Hinson, T., Sridharan, A., Kolodner, K., & Howell, E. (2009). A quality improvement intervention to
facilitate the transition of older adults from three hospitals back to their homes. Journal of the American Geriatrics Society, 57(9),
1540-1546. http://dx.doi.org10.1111/j.1532-5415.2009.02430
Denson, L. A., Winefield, H. R., & Beilby, J. J. (2013). Discharge-planning for long-term care needs: the values and priorities of older
people, their younger relatives and health professionals. Scandinavian Journal of Caring Sciences, 27(1), 3-12 10p.
http://dx.doi.org/10.1111/j.1471-6712.2012.00987.x

23. References Continued
Foss, C., & Askautrud, M. (2010). Measuring the participation of elderly patients in the discharge process from hospital: a critical
review of existing instruments. Scandinavian Journal of Caring Sciences, 2446-55, 10p. http://dx.doi.org/10.1111/j.1471-
6712.2010.00788.x
Greysen, S. R., Hoi-Cheung, D., Garcia, V., Kessell, E., Sarkar, U., Goldman, L., & ... Kushel, M. (2014). 'Missing pieces'-functional,
social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. Journal of the American
Geriatrics Society, 62(8), 1556-1561 6p. http://dx.doi.org/10.1111/jgs.12928
Hyrkas, K., & Wiggins, M. (2014). A comparison of usual care, a patient-centered education intervention and motivational interviewing
to improve medication adherence and readmissions of adults in an acute-care setting. Journal of Nursing Management, 22(3), 350-361
12p. http://dx.doi.org/10.1111/jonm.12221