Reducing Hospital Readmissions

Thursday, 25 July 2013: 8:30 AM

Karla Zengerle-Levy, PhD, RN-BC, GNP-BC
Professional Development, University of Texas Medical Branch, Galveston, TX

Learning Objective 1: Upon completion of educational programs, the learner will be able to successfully recognize common elder maladies within the community-based settings.

Learning Objective 2: Upon completion of educational program, the learner will be able to articulate best practices of common elder maladies.

Purpose: The Geriatric Resource Nurse (GRN) Community Project is designed to improved outcomes for elders across healthcare settings. The purpose of this project is to improve knowledge, practices, and collaboration by registered nurses at a university hospital and community agencies providing geriatric care. The project's overarching goal is to reduce readmissions to the hospital.

Methods: The descriptive study examines the nurses’ knowledge. A convenience sample of 121 nurses from five community based agencies and 18 nurses from a university hospital constituted the participants. Guided by the GRN model developed at the Hartford Institute’s Nurses Improving Care to Healthsystem Elders (NICHE) model, a gerontology nurse practitioner designed original modules and modified NICHE modules, coordinated schedules, and co-presented modules. The modules were presented by two nursing educators to maintain content continuity. Additionally, nurses from participating agencies shadowed each other on a rotational basis to gain an appreciation of the role and resources each agency provided or lacked. Finally, gerontology specialists (such as nutritionist, psychologist, and physicians) presented education sessions.

Results: Pre and post assessment demonstrated an accumulative improvement in gerontology knowledge and best practice in multiple areas. Community based elder agencies’ antidotal reports demonstrated a decrease in hospital admissions and emergency department visits. The university hospital reported increase in hospital admissions from clinics; however, at the time of this submission, it cannot be stated that these admissions were related to elders that dwell in a community based agency or dwell independently in the community. Given there was no control group, it cannot be empirically stated that the education programs,  interagency networking or interdisciplinary engagement were directly related to the outcomes.

Conclusion: This pilot study suggest that continued gerontology education in the community and university setting, creative networking strategies, and interdisciplinary engagement can enhance coordination and continuity of elder care which benefits agencies, elders, and their families.