The Article: Berry, D., Costanzo, D., Elliott, B., Miller, A., Miller, J., Quackenbush, P., & Su, Y. (2011). Preventing avoidable hospitalizations. Home Healthcare Nurse, 29(9): 540-549.

The Big Idea: Patients are being discharged from the hospital earlier and earlier, making rehospitalization after discharge more common. A healthcare agency in New Jersey adapted the Transitional Care Model (TCM), which is a nurse-led multidisciplinary model, to “(1) reduc[e] avoidable rehospitalization of Medicare beneficiaries enrolled in the project within 30 days of discharge, (2) reduc[e] ED visits during home care admissions, (3) improv[e] transitions of care from one provider setting to another, (4) remain cost neutral, and (5) improv[e] patient safety through coordinated patient transfers” (p. 542).

Survey Says!: The pilot program enrolled 98 patients and did show a gradual decrease in hospital readmissions, improved communication with emergency departments, and emphasized the importance of strong, thorough follow-up care after discharge.

Quotable: “Jencks et al. (2009) analyzed Medicare claims data for nearly 12 million FFS Medicare beneficiaries discharged from hospitals in 2003 and 2004. They reported that approximately one fifth of all patients who were discharged from the hospital were rehospitalized within 30 days, 31.1% within 60 days, and half within 1 year. It is estimated that the cost to Medicare for unplanned rehospitalizations in 2004 was $17.4 billion. For half of the patients who were readmitted within 30 days, there was no bill for a physician visit during that time period. This lack of continuity hampers positive outcomes. Evidence suggests that rehospitalizations
can be reduced by systemic changes to the healthcare system, including improved transition planning, quick follow-up physician
care, and consistent treatment of chronic illnesses (Jencks et al., 2009)” (p. 541).

So What?: This is a great article discussing “chronic” navigation as well as strengths and weaknesses of the transitional care program. It contains care pathways as well as specific interventions and metrics the organization used to reduce hospitalizations.