One in five elderly patients discharged from the hospital is readmitted within a month, according to a study in Health Affairs. To mitigate the readmissions, researchers at the University of Pennsylvania School of Nursing found transitional care can improve outcomes and reduce readmissions, specifically with the utilization nurses.
The study indicated that nurse managers with master's degrees, particularly, should work with the patient, the patient's family and other providers to identify goals, inform patients about community resources and establish ways to prevent poor outcomes.
"The good news is that available evidence provides those responsible for implementing community-based care transitions programs, accountable care organizations and other innovative delivery and payment models with a strong foundation upon which to build these programs and achieve better care and better outcomes while reducing costs" said lead author Mary Naylor, PhD, RN, a professor at the University of Pennsylvania School of Nursing. "If we capitalize on what we know, the real beneficiaries will be those living with complex chronic conditions and their family caregivers."
As healthcare organizations struggle to fill the void of physicians in short supply, many facilities heavily rely on other providers, including nurses. However, staffing and scheduling will become increasingly important.
In contrast to this Health Affairs study, a previous study last month showed that higher levels of nurse overtime increased readmissions. However, when hospital units added more registered nurses, RN overtime was reduced and readmission rates dropped, according to Health Services Research.
To learn more:
- here's the Health Affairs study abstract
- read the UPenn press release