TRANSITIONAL CARE: A NURSE-DRIVEN PROGRAM TO IMPROVE PATIENT OUTCOMES
Bates, Mary A.
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Increased scrutiny over the spiraling costs of health care and inefficiencies within the health care system has focused attention on readmissions to acute care that occurs within 30-days of discharge. The Centers for Medicare and Medicaid Services (CMS) have identified these early readmissions as an indicator of poor quality care. With one-fifth of Medicare beneficiaries who will experience early readmissions, it is imperative that a patient centered approach be implemented that will decrease functional dependence and increase quality of life in this vulnerable population (“The Partnership for Patients,” 2012; Toscan, Mairs, Hinton, & Stolee, 2012). Unplanned and often unnecessary readmissions affect 2.6 million seniors per year at a cost of more than $26 billion (Axon & Williams, 2011; Bhalla & Kalkut, 2010; D’Amore, Murry, Powers, & Johnson, 2011; Hasan et al., 2009; Horwitz et al., 2011). Research by Anderson, Helms, Hanson, & DeVilder (1999) found that a breakdown in communication during the transition process was the most common factor in the occurrence of early readmissions and a significant source of poor patient outcomes (Steffens et al., 2009). A reduction in readmissions can be achieved through improved discharge planning, an improved process of communication between providers and through a nurse-driven program designed to transition patients more effectively.