Overview

• 33 magnet-designated hospitals integrated the use of structured nurse assessments of patient readiness for discharge into medical surgical unit discharge practices in an effort to decrease 30-day readmission rates.

National/Policy Context

• The Medicare Hospital Readmission Reduction Program resulted in three-fourths of United States hospitals facing financial penalties. This led many hospitals to re-prioritize readmission avoidance initiatives.
• The use of clinical assessment tools to evaluate patients for discharge readiness has been recommended as an addition to the standard of care for discharge preparation. Several observational studies have shown that these tools are effective in addressing tasks that should be performed prior to discharge in order to decrease 30-day readmission rates.

Patient Population Served and Payor Information

• The patient population served by this intervention was 65% White, 14.5% Black, and 3.3% Asian.
• 29.3% of patients had private insurance, 40.2% had Medicare, 13.8% had Medicaid, and 2.4% were uninsured

Leadership

• Marianne E. Weiss, DNSc, RN, Marquette University College of Nursing
• Olga Yakusheva, PhD, University of Michigan School of Nursing, Ann Arbor

Funding

• American Nurse Credentialing Center (ANCC) funded the project through a competitive application process.
• The hospitals that participated in the project paid a fee to the ANCC to participate.

Research + Planning

• Staff for the American Nurse Credentialing Center of the American Nurses Associations recruited hospitals by telephone to participate in this project.

Tools or Products Developed

• READI1: A structured nursing assessment that instructed the discharging nurse to complete a patient assessment (for readiness of discharge) on the day of discharge. This assessment was completed using the Readiness for Hospital Discharge Scale nurse form (RN-RHDS).
• READI2: A structured nursing assessment identical to READI1 with the addition of a patient self assessment for readiness of discharge (RHDS PT-RHDS) which the nurse was required to review before completing the RN-RHDS.
• READI3: A structured nursing assessment that that included READI1 and READI2 with the addition of a required documentation of a score less than 7 out of 10 on either the RN-RHDS or the PT-RHDS. It also required documentation of action to improve readiness for discharge and reduce readmission.

Training

• Previously employed nurses assigned to the intervention units attended a mandatory training two weeks prior to implementing each protocol. Training included an overview of prior research on discharge readiness, the association of studied research with postdischarge outcomes, and instruction on how to implement the protocol.
• For nurses who were hired during the implementation, the training was incorporated into their new employee orientation.

Tech Involved

• Electronic medical record

Team Members Involved

• RNs

Workflow Steps

• Discharge nurses were required to complete one of the three variations of discharge readiness nursing assessment protocols (READI1, READI2, and READI3) within four hours of anticipated patient discharge. It usually took the nurses 2 minutes to complete the form, and it took patients between 2-5 minutes.
  • The discharge readiness assessment protocols were used as a structured assessment of discharge readiness and included instructions for nurses.
  • They focused on capturing a patient’s personal status (physical status and level of energy), a patient’s understanding of the things to look out for regarding their condition and restrictions, the physical tasks patients were allowed to perform at home, and expected post-discharge support.
• Each patient was randomly assigned to one of the three protocols (READ1, READ2, or READI3).
• If the nursing assessment score for a patient was too low, nurses performed and documented actions they took to improve patient readiness for discharge and reduce readmission within the four hours before patient discharge.

Budget Details

• Cost of participation fee to the ANCC paid by each hospital involved in the intervention

Where We Are

• The project is complete.
• It took place between September 15, 2014 and March 31, 2017.

Outcomes

• 30-day readmission rates: Rates were measured as either readmission to inpatient, emergency department, or observation units.
  • Total: Of the 144,868 patient discharges studied, 12.2% were readmitted and 8.8% had an emergency department visit or observation stay.
  • None of the protocols reduced return to hospital rates in the full sample.
  • Implementing the READI2 protocol, which required patient self-assessments, reduced return to hospital by 1.79% (p=0.009) on high readmission units.

Benefits

• This project revealed the importance of incorporating patients’ voices in clinical decision making about discharge readiness and effectiveness.

Unique Challenges

• The 30-day readmission rates at the hospitals involved in the intervention varied from low to high prior to the intervention, so it was difficult to account for the exact impact of the intervention in each unique setting.

Sources

Weiss ME, Yakusheva O, Bobay KL, Costa L, Hughes RG, Nuccio S, Hamilton M, Bahr S, Siclovan D, Bang J; READI Site Investigators. Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital: The READI Randomized Clinical Trial. JAMA Netw Open. 2019 Jan 4;2(1):e187387. doi: 10.1001/jamanetworkopen.2018.7387. PubMed PMID: 30681712.