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Another Look at Readmissions. Katie Westman, RN, CNS United Hospital. Caring for the person…in context. Reason for Readmissions. Progression of disease Unrelated to original hospitalization Preventables Medications, medications, medications Lifestyle – smoking, for example
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Another Look at Readmissions Katie Westman, RN, CNS United Hospital
Reason for Readmissions • Progression of disease • Unrelated to original hospitalization • Preventables • Medications, medications, medications • Lifestyle – smoking, for example • Access – primary knowledgeable about disease state, regular testing, healthy foods, exercise, patient education, social support, finances
Tactics • Better assessments in the acute care setting • Identifying “hidden” needs (medication adherence, cognitive abilities, mental health issues, literacy) • Cognitive assessments • Transition conferences • Involving support system • Comprehensive discharge planning • Redesigning the discharge process • Simplifying and communicating • Involving patients and support systems • Appropriate placement
Questions to Think About Before the Conference Here are some things to think about as you plan to transition from the hospital: • 1. Who usually helps you with your everyday activities at home? • Food? Medicine? ADLs? • How would you contact that person? • 2. Who helps you make decisions about your health care? • 3. Whom do you call when you have questions or concerns about your health? • How do you get to your health care appointments? • 4. Do you have any concerns about how you will pay for your health care needs?
Transition care support • Transition coaches, APRNs, community support • Transition communications • Allina transition conferences • http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/PASS.pdf