Reducing hospital readmissions is at the forefront of heathcare organizations across the country. The Affordable Care Act (ACA) began penalizing hospitals with high readmission rates as of October 2012. Since that time, resources, programs, and initiatives have been growing exponentially. Reducing hospital readmissions appears to have taken on a life of its own. Numerous hospitals report the amount of resources they are putting toward reducing readmissions is causing great concern.
It is important for organizations to look internally prior to focusing on developing new initiatives or programs. The most valuable resources may very well be located within the organization itself. An example of such is nutrition. Nutrition concerns have long troubled physicians and clinical staff alike. Poor nutrition leads to slow healing, increased risk of complications, longer hospital stays and higher rates of admission to long term care facilities.
Addressing the nutritional needs of the senior population is not a new concept. Nutrition is often a problem among seniors before hospitalization. Adult day care programs provide nutritional meals and education, home health agencies provide meal assistance preparation and support, and Meals on Wheels has been providing services to the homebound for years. Tapping into these resources and marrying the function with the planning that goes on while patients are in the hospital establishes a collaborative approach that will reach well beyond the hospitalization and support patients and families.
Many initiatives have been implemented within the hospital to screen the nutritional needs of patients, especially to seniors, these programs have facilitated the development of comprehensive care plans to treat patients and prepare for discharge. Expanding this process to assess, educate, and screen for post discharge needs may provide a comprehensive reduction strategy.
Utilizing those team members intricately involved in-house, such as dieticians, educators, care planners, social workers and case managers, may broaden the program into the post discharge arena and assist family members, rehabilitation, and skilled nursing facilities. These will not require new resources, but the expansion of the program beyond the inpatient arena.
In Olathe, Kansas, a program is under development with the local Meals on Wheels and the county’s health department to work with hospitals to coordinate the transition from hospital to home by delivering frozen meals to home bound patients within 72 hours of discharge from the hospital. Patients will also be followed by outreach nurses to assess for compliance, additional risk, and the need for additional support. Too often, seniors on a fixed income will rely on fast food when they are released from the hospital. This food is easy to obtain, although often not nutritionally sound, and inexpensive. These meals can lead to further complications, such as increased sodium intake, especially for those with heart failure.
These services can not only provide meals to seniors but they can assure patients follow any physician directed nutritional requirements, such as low sodium, diabetic diets by tailoring meals to each patient. The program will provide nutritious meals and education in addition to peace of mind – the patients will not need to be concerned about shopping, transportation, or finding someone to prepare the meals.
Not all readmissions are preventable, but by carefully examining those practices currently addressed within the hospital during admission, and expanding those initiatives into the post-discharge environment hospitals may begin to realize new or additional resources, technology, and programs may not be necessary. Providing healthy food and meals and removing the concern about an empty refrigerator may be just what the doctor ordered.