Survey respondents

Preventing readmissions through enhanced care team collaboration

By Michelle McCleerey  /  27 Apr 2016

The Journal of the American Medical Association recently published a study which revealed that more than one in four hospital readmissions are potentially preventable. The underlying issue behind many of the key factors contributing to preventative readmissions? A lack of care team communication and collaboration—particularly between inpatient and outpatient team members. This is consistent with findings from a recent independent survey conducted by Nielsen which found that  95 percent of physician and nurse respondents believed that successful care team collaboration is key to reduced readmissions.

The JAMA study results revealed that the strongest significant predictors of preventable patient readmissions were the following:

  • Premature discharge from the initial hospitalization;
  • Failure to relay important information to outpatient care professionals;
  • Lack of discussions concerning care objectives with those patients with serious illnesses; and,
  • Emergency department decision-making to admit a patient who may not require an inpatient stay.

In accordance with the evidence, and based upon my experience as a nurse, there are a few ways care teams can avoid preventable readmissions:

  • Effective discharge planning across the entire care team—Both inpatient and outpatient care team members must actively participate in discharge planning to ensure the correct disposition and care venue for the patient. Outpatient appointments must be consistently scheduled within the needed time frame based upon the patient’s condition. Additionally, a comprehensive assessment of the patient needs and strategies to address the same must be identified.
  • Patient and family as active care team members—Patients and their family members must be full participants on the care team. It is essential for patients to contribute to and be aware of the comprehensive discharge plan to ensure that all patient/family needs will be addressed. Patients and their family members need to actively be engaged in their own care, beginning from the point of inpatient admission and extending throughout outpatient care and health management.
  • Increased collaboration between the emergency department and primary care providers—With the emergence of the hospitalist role, the common venue between primary care and the emergency room physicians has virtually been eliminated. Consequently, primary care physicians are often unaware of the patient’s visit to the emergency department and any information that is provided to them is often lacking and delayed. However, the decision to admit the patient to the hospital is dependent upon whether the patient has timely access to follow-up care. If the primary care and emergency physicians are able to efficiently connect and exchange needed information, unnecessary hospital admissions can be avoided.

As the Nielsen study found, obstacles to care team collaboration still impede such strategies, as care team members frequently do not know the correct team member to contact and waste valuable patient care time struggling to do so. Technology is needed to immediately identify and automatically connect the right care team members in order to facilitate timely collaboration. Importantly, enabling technology must provide this capability across the entire continuum and not be constrained by the four walls of the hospital.

As the healthcare industry transitions from a fee-for-service system, we must expand our focus from “discharge” to care continuity. No longer can we discharge responsibility for a patient to another care setting. Rather, we must shift our perspective and provide continuous coordinated care across multiple sites and settings. To do this efficiently, enabling care team collaboration technology is imperative.

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