Bridging the Gap in Care to Prevent 30 Days Readmissions

Background: In the United States 30 day hospital readmissions is a national concern; this problem is significant because it is costly and is a poor indication of the quality of our healthcare delivery system. Patients face many challenges after hospitalization; a concerted effort is needed to improve care during the health and illness transition phase.

Purpose: The purpose of this project is to heighten awareness on the importance of post hospital discharge transitional care. Create and implement a post hospital discharge follow-up protocol in a primary care setting to reduce the prevalence of 30 day readmissions in the diabetic and hypertensive population in the practice.

Theoretical Framework: The theoretical framework selected by the researcher for the capstone project is based on the middle range Transition Theory of Drs. Afaf Ibrahim Meleis, Dr. Eric Coleman Care Transitions Program model, and Kurt Lewin Change Theory.

Methods: To conduct a descriptive study. To examine de-identify data to identify gaps in transitional care. To introduce and implement a post hospitalization transitional care protocol in a primary care setting to address diabetic and hypertensive patients post discharge needs during the health and illness transition phase to improve health outcomes.

Results: A sample size of 80 de-identified data was analyzed. It included 40 de-identified records pre-protocol intervention, and 40 post discharge intervention protocol. Data was categorized into two groups diabetic and hypertensive groups, and into two categories those who had follow up with their primary care physician post discharge and those who did not. A Chi-square Fisher Exact test was conducted in SPSS. Based on the results there was no significant statistical difference between the pre and post intervention groups. However, based on the numbers less people were admitted post protocol intervention.

Recommendations

More studies are needed with larger sampling size as this may impact statistical results. Studies focusing on the causative factors of 30 day readmissions may provide in-depth understanding of the phenomenon of 30 day readmissions. More advocacy work is needed to influence policy makers and the insurance industry in making transitional care a standard of care for all.

Conclusion

Because of the penalty imposed by Medicare on hospitals for 30 day readmissions of patients with specific diagnoses; the focus has been on preventing readmissions of Medicare patients. Medicare provides a special ICD 10 code with special reimbursement rates for post hospitalization transitional care face to face visit with primary care physicians that occurs between 7-14 days. To improve health outcomes transitional care must be recognized as a standard of care for all patients regardless of payer source and diagnoses.