Running head: BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

Barriers That Lead to Hospital Readmissions

Kendra Calonita
Western Washington University

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

Barriers That Lead to Hospital Readmissions

Introduction
While working in the hospital I would often see patients readmitted with the same
diagnosis after having been discharged only a couple weeks prior. Many readmissions were due
to the fact that proper discharge planning and follow-up care was not being executed as well as it
should have been. Many patients were being discharged without receiving proper education
about their diagnosis, how to care for themselves at home, complications to look for and when to
follow-up with their doctor. In my experience, most of the patients who were readmitted werent
able to care for themselves and needed caretakers. This requires in-depth discharge planning and
follow-up care. Having experience with patient care and seeing patients being readmitted
frequently sparked my interest in the importance of reducing hospital readmissions and the role
that nurses have in the discharge process and patient outcomes. The topic I chose, barriers that
lead to hospital readmissions relates to the Institution of Medicine Report recommendations
because they believe it is important that nurses have the opportunity to lead and direct efforts to
improve the healthcare system. Nurses play an important role in the discharge care of a patient,
starting from when the patient is admitted to the hospital and continuing until they are discharged
to home or an extended care facility. Creating a patient-centered care model is crucial in order to
deliver the discharge care that patients deserve. It is important that an effective system be put in
place not only to decrease the amount of hospital readmissions, but also to decrease the cost to
the patients, the hospitals and the insurance companies. Hospital readmissions are rising because
of failure to initiate the discharge process when patients are admitted to the hospital, failure to
follow up after a patient is discharged from the hospital and lack of interdisciplinary
communication which leads to poor patient teaching.

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

Finding Sources
When discovering that we were going to be writing a source analysis paper and that we
had the freedom to pick the topic, I immediately thought about my interest in discharge planning
and poor patient outcomes. When beginning the research process, I initially Googled my topic to
make sure that there was an adequate amount of research that had been done. I was then able to
log on through the schools library database in order to find a literature review article and several
peer-reviewed articles. When searching the Cumulative Index to Nursing and Allied Health
Literature (CINAHL) database, I used keywords such as: discharge planning, patient outcomes,
mortality, hospital readmission, patient satisfaction, and compliance. Using these keywords
helped me to narrow down the number of articles related to my topic.
I was able to find four articles that focused on this topic: a literature review examining
the effectiveness of early discharge planning programs, a peer reviewed article exploring the
impact of post-discharge telephone calls, a peer reviewed article about factors that contribute to
increase readmissions and another peer reviewed article speaking about discharge planning and
the barriers.
Summary and Analysis
Poor Communication
The most commonly believed factor that leads to increased hospital readmission by both
the patients and healthcare workers, is the inadequate communication between the patient and
healthcare workers and between the healthcare team. The conclusions of the DeCoster, Ehlman

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

and Conners (2013) study were that both provider-patient and provider-provider communication
was one of the leading causes to increased hospital readmissions because patients were not
properly educated on how to manage their health and the information exchanged between
providers was insufficient.
In the study done by DeCoster et al. (2013), about analyzing the factors that lead to
hospital readmission they determined that above all other factors, communication is the biggest
issue that causes readmission. Multidisciplinary team coordination, specifically the use of
interdisciplinary hospital rounds and an interdisciplinary team worksheet, was a critical element
in the success of a care transition program evaluating elders transitions from hospital to home
(as cited by Dedhia et al., 2009). Building a better communication path between the healthcare
team will enable patients to receive the quality care that they deserve.
Harrison, Hara, Pope, Young and Rula (2011) state, that poor communication between
provider-provider and provider-patient during the discharge process leads to increased
readmission rates. Interventions to decrease the amount of hospital readmissions are attainable.
The hospital discharge intervention described by Harrison et al. (2011) was established with the
intention of improving patient outcomes, enhancing patients health by educating them with the
necessary tools and information so that they were able to be involved in caring for themselves,
and decreasing the costs for both patients and hospitals. Initiating this discharge intervention
would not only increase patient satisfaction but it would also allow patients to become more
healthy and independent with their care.
Excellent communication is pivotal in providing the quality care that patients deserve.
Patient outcomes are directly affected not only by patient-healthcare worker communication but

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

also by communication between healthcare workers. Coming up with a discharge plan to keep
all multidisciplinary members of the healthcare team on the same page would not only provide
patients with outstanding care, but would also help to prevent hospital readmissions.
Beginning the Discharge Process on Admission
Beginning the discharge process the moment the patient is admitted to the hospital proves
to enhance care not only throughout the hospital stay but also when the patient is transitioning
from the hospital setting into the community. Zhu, Liu, Hu and Wang (2015) found that with
early discharge planning, compared to standard care, this intervention has positive effects in
reducing hospital readmission, readmission LOS, and all cause mortality (pg. 3001). Zhu et al.
(2015) defined early discharge programs as, initial nurse visit within 48 hours of hospital
admission, predischarge assessment, structured home visits and telephone follow-ups after
discharge (pg. 2994).
Early discharge planning has proved to increase patient care and decrease hospital
readmission. By decreasing hospital readmission, one can also assume that healthcare costs
would also decrease. It takes the entire multidisciplinary team in order to provide proper in
hospital care, discharge planning, and post discharge care. The nursing staff has the most
important role in discharge planning for a patient in the hospital, however there are many
obstacles that nurses face when providing quality discharge care. According to, Graham,
Gallagher and Bothe (2013), These challenges include insufficient time to plan, maintaining
continuity of care when there is increasing patient complexity, frequent patient transfers,
unplanned admissions and nurse turnover and reduced length of patient stay (as cited by
Williams 1991, Watts & Gardner 2005, Duffield et al. 2007, Foust 2007).

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

Education on how to provide a patient with quality discharge care is another problem that
nurses are running into. Graham et al. (2013) found that, many nurses in this specific study felt
that they didnt comprehend the discharge process and that they were uneducated on what steps
to go through in order to properly discharge a patient. That many only started to learn the
discharge process once they were working and that they were expected to know how to properly
discharge from previous experience. Graham et al. (2013) states that regardless of the many
tasks that nurses face, they play a crucial role in beginning the discharge process because during
their initial admission assessment is when it is important to start identifying the patients needs
after discharge (as cited by Rorden & Taft 1990, Bull & Roberts 2001, Watts & Gardner 2005,
pg. 2344).
Follow-up Care after Discharge
Hospital readmissions have a high occurrence and are very expensive for both patients
and healthcare insurers. Many of these hospital readmissions are preventable if healthcare
providers are giving patients adequate pre and post discharge care. When healthcare providers
do not provide follow up care with their patients after discharge that leads to increased hospital
readmission.
In the study done by Harrison et al. (2011), to decrease the rate of hospital readmissions
they discover that following up with patients after discharge has a positive impact on decreasing
the rate of hospital readmission, which in turn decreases the cost of healthcare. Follow-up
telephone calls made by well-informed nursing staff, within 14 days of a patient being
discharged from the hospital would provide the patient with the education and support they need.

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

According to the study performed by Harrison et al. (2011) the telephone calls made by nursing
staff resulted in savings of approximately $1.4 million (pg. 30).
Readmission to the hospital within 30 days of discharge is a significant problem amongst
the chronically ill and the elderly. It is hard on the patients and is very costly to the healthcare
system, especially Medicare in that a large percentage of readmissions are of Medicare patients.
The readmission rate can be reduced by better post discharge communication with the patient.
The Harrison et al. study identified that a telephone call to the patient within 14 days of
discharge explaining their care plan and self-management of their condition significantly reduces
the patients likelihood of readmission within the 30 post discharge period studied.
The rate of hospital readmission is increasing due to the lack of initiating the discharge
process when a patient is admitted, failing to follow up after discharge, and inadequate
communication between interdisciplinary members and their patients. Healthcare workers are
arguing that they lack the knowledge to properly discharge patients. These are some of the
findings in the study performed by Decoster et al. (2013).
Synthesis
Decreasing hospital readmissions and overcoming the barriers to decreasing hospital
readmissions is a challenge among the healthcare field. Decoster et al. (2013) and Harrison et al.
(2011) agree that communication stands as the greatest barrier within the discharge process
leading to poor patient teaching and increased hospital readmissions. Communication between
both healthcare workers and their patients needs to be coordinated accordingly so that patients
are given the tools and education they need in order to be successful once discharged from the
hospital.

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

Zhu et al. (2015) argue that beginning the discharge process on admission not only
improves the patients stay at the hospital but also helps when transitioning from the hospital to a
home setting. Graham et al. (2013) point out that many nurses lack the education on how to
provide quality care while discharging a patient. Educating employees on how to thoroughly
discharge patients is something that hospitals should begin doing if they want to not only
improve on patient outcomes and satisfaction but also lessen hospital readmissions and the cost
that they entail.
The Harrison et al. (2011) study found evidence that post-discharge telephone calls made
a difference in decreasing the rate of hospital readmissions. Following up with patients after
discharge and continuing to provide them with the education they need enabled patients to
become healthier and also reduced the amount of hospital readmissions. Providing patients with
the information they need in order to maintain their health outside of the hospital setting is a
crucial role of healthcare providers, especially nurses.
Conclusion
As soon as I began working in the hospital my interest in hospital readmissions and the
role the nurse has when discharging a patient began. I started my research thinking that the
discharge process began right before the patient discharges either to home or to an extended care
facility. I also didnt realize how interrelated discharge planning and hospital readmissions were.
However, after being able to analyze and review several articles I now realize that there are many
layers to the discharge process and creating a patient-centered discharge model will help to
decrease hospital readmissions.

BARRIERS THAT LEAD TO HOSPITAL READMISSIONS

Many patients are re-hospitalized each year, but there are ways that nurses and other
healthcare professionals can prevent that. Nurses have the most contact with patients while in
the hospital and play a vital role in the discharge process. Enforcing a patient-centered care
model that ensures patients proper discharge planning is critical. This should include starting the
discharge process as soon as the patient is admitted to the hospital, providing post-discharge
follow-up care, and enhancing provider-provider and provider-patient communication will
ultimately help to decrease hospital admissions.
This assignment has allowed me to gain greater knowledge about the barriers that lead to
hospital readmissions, the role that nurses play in the discharge process and the importance of
developing a discharge model to decrease hospital readmissions and increase patient satisfaction.
This assignment has challenged me to become both a better academic reader and writer and
lastly a better nurse.

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References
DeCoster, V., Ehlman, K., & Conners, C. (2013). Factors contributing to readmission of seniors
into acute care hospitals. Educational Gerontology, 39(12), 878887 10p.
http://doi.org/10.1080/03601277.2013.767615

Graham, J., Gallagher, R., & Bothe, J. (2013). Nurses discharge planning and risk assessment:
behaviours, understanding and barriers. Journal of Clinical Nursing, 22(15/16), 23382346
9p. http://doi.org/10.1111/jocn.12179

Harrison, P. L., Hara, P. A., Pope, J. E., Young, M. C., & Rula, E. Y. (2011). The impact of
postdischarge telephonic follow-up on hospital readmissions. Population Health
Management, 14(1), 2732 6p. http://doi.org/10.1089/pop.2009.0076

Zhu, Q.-M., Liu, J., Hu, H.-Y., & Wang, S. (2015). Effectiveness of nurse-led early discharge
planning programmes for hospital inpatients with chronic disease or rehabilitation needs: a
systematic review and meta-analysis. Journal of Clinical Nursing, 24(19-20), 29933005.
http://doi.org/10.1111/jocn.12895