Prevent Readmissions With Nurse Intervention

Rebecca Hendren, for HealthLeaders Media , September 27, 2011

Many patients with chronic illnesses face complicated medication regimens they may not understand, have prescriptions that need to be filled, or wonder what to do about prescriptions they had been taking before hospitalization.

“We had to go to the home and see it,” Costa says. “It was the only reliable way to really know what [their] medication management is.”

In the home visits, the nurses could determine patients’ understanding about managing their medications. Nurses called the patients two days after discharge to talk about their medications, then visited patients’ homes two weeks after they had left the hospital.

The home visit “was really the way we could see what was going on, as far as medication went,” says Costa. “We could look at the bottles, see how they organized medications [and] filled prescriptions, if they understood what medications they were supposed to be taking.”

The nurses identified discrepancies between treatment plans and what patients were doing post-discharge. “Many discrepancies were not intentional,” says Costa. “Patients were just confused with the instructions.”

Study participants were taking about 10 medications on average, so instructions were plentiful and complicated. The nurses were surprised to learn that money was usually not the barrier to medication adherence. “A lot of patients did have supplemental help because they were lower-income,” Costa says. “The problems were mostly in not understanding or deciding not to take a medication.”

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3 comments on "Prevent Readmissions With Nurse Intervention"

Amy (12/11/2011 at 6:38 PM)
It's great to see this article. I've worked in both the hospital and home setting as a nurse for about 10 years now. I've seen first hand what can happen between the hospital discharge to home. It's been sometimes amazing what you might find once you go into a home. Medications is definitely a big one and many times is related more to understanding rather than financial. I've been fortunate to learn a lot from working in both areas and try to incorporate what I've learned in my everyday practice whether in the hospital or the home.

Matt (9/30/2011 at 11:06 AM)
Did the study have an ROI? Or was it just money spent to reduce readmissions? Is it feasible fiscally to have nurses that make home visits? APNs or RNs?

Naomi Ervin (9/30/2011 at 10:51 AM)
It is great to see that home health care nursing has been re-discovered. This type of nursing service has been available for over 100 year. Numerous studies have demonstrated the effectiveness for early discharge and preventing re-admissions.




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