Readmissions Intervention: Planning Phase

Introduction to the Problem

The role of transitional care in ensuring positive patient health outcomes after discharge is essential. Readmissions and repeated hospitalizations lead to high costs of health care services and lower patient satisfaction (Leppin et al., 2014). In this regard, increased attention to the mentioned issues may be noted from the Centers for Disease Control and Prevention (CDC) and other national organizations that work on the provision of relevant nursing practice guidelines. The problem of readmissions leads not only to additional costs but also to poor quality care as well as low effectiveness of interventions applied to patients.

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Problem Identification

The main problem that should be addressed is high readmission rates resulted from poor outpatient or inpatient care as well as inappropriate planning. “One in 5 Medicare beneficiaries is readmitted within 30 days, for example, at a cost of more than $26 billion per year” (as cited in Leppin et al., 2014). Readmission may be defined as a patient’s return to the hospital within several days or months with the same problem after the discharge.

If some repeated hospitalizations may be important to provide the required services, many others may be prevented using proper discharge planning and the subsequent follow-up initiatives. In particular, the evidence shows that a team of nurses who monitor patients during their stay at a hospital should then continue to educate, solve problems, and speak in support of patients within 30 days of discharge (Leppin et al., 2014).

The problem is complicated by vague definitions of such concepts as potentially preventable hospitalizations and inappropriate readmissions. Various diseases that led to readmission seem to be deteriorated by a lack of proper patient self-care and self-monitoring. For example, one may state that heart diseases, pneumonia, and hypertension are among those health concerns that are most of all associated with repeated hospitalizations.

Significance of the Problem to Nursing

The identified problem is rather important to nursing as it serves as the cornerstone of healthcare services. Namely, nurses are the key providers of care, who are aware of the patients’ needs, expectations, preferences, and other peculiarities, which are essential to take into account. More to the point, by addressing the problem of readmission prevention, nurses may obtain such benefits as more human resources, increased care quality, and improved communication with patients and colleagues (Verhaegh et al., 2014).

There is a need to work together with nurses and patient management staff at the hospital is likely to lead to exchanging information with the treating physician of every patient, specialist, or other care team members. Therefore, nursing may significantly contribute to the problem elimination based on continuous care, including home visits, telemonitoring, and pre-discharge planning.

Another important point that should be noted is associated with the fact that nurses are directly involved in care planning and provision. Since they are expected to focus on patient education as an integral part of treatment, they have the potential to enhance the situation with readmissions and repeated hospitalizations. The recent study performed by White, Garbez, Carroll, Brinker, and Howie-Esquivel (2013) shows that the conceptual model of teaching back may be quite effective. The essence of this model lies in asking patients about the information that was presented to them, thus ensuring their adequate self-care. These results illustrate the significance of the problem to nursing as the key mediator of interventions to reduce readmissions.

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Purpose of the Research

In the view of the mentioned information, it becomes evident that the paramount goal of the research is to understand the causes of the specified problem and provide potential evidence-based solutions. To accomplish these purposes, it is critical to review the existing scholarly literature and identify any gaps and potential recommendations (Verhaegh et al., 2014). It is also important to critically discuss discharge planning aspects based on transitional care and an interprofessional team of health care providers. In general, the research purpose is to contribute to the theory of nursing in the field of pre-and post-discharge patient health outcomes.

Research Questions

The following research questions may be formulated:

  • What are the main definitions and causes of hospital readmissions?
  • What are the consequences of this problem regarding patients, nursing, and healthcare as a whole?
  • How can the problem of repeated hospitalizations be addressed?
  • How to measure the effectiveness of potential interventions associated with discharge planning and follow-up?


Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K.,… Ting, H. H. (2014). Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095-1107.

Verhaegh, K. J., MacNeil-Vroomen, J. L., Eslami, S., Geerlings, S. E., de Rooij, S. E., & Buurman, B. M. (2014). Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Affairs, 33(9), 1531-1539.

White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? Journal of Cardiovascular Nursing, 28(2), 137-146.

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