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Pilot Projects: Newton-wellesley's STAAR Initiative Aims To Reduce Avoidable Readmissions

Monday July 11, 2011
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RNs at Newton-Wellesley Hospital are working to keep discharged patients from unnecessarily returning to their hospital beds.

Better education about post-discharge care, making sure staff is aware of all medications before a patient leaves and checking in with patients after their stays are among the strategies the Newton, Mass., facility is using to reduce avoidable readmissions.

Beginnings
Newton-Wellesley began participating in the Institute for Healthcare Improvement’s State Action on Avoidable Readmissions initiative in September 2009. The project is being piloted on two units at the facility, including a medical unit where heart failure patients are being targeted, and an orthopedic surgical floor.

“If you come to the hospital and your discharge diagnosis is congestive heart failure, and within 30 days you come back to the hospital again with that same diagnosis, our question is, could we have possibly avoided you coming back?” says Cheryl Bardetti, RN, BSN, quality and safety RN specialist and STAAR day-to-day leader at Newton-Wellesley. “We want to make sure we’ve covered all the elements.”

Those elements include providing patients education and information about their care before surgery, rather than after when they might be groggy or distracted. RNs also review information with patients using teach-back methodology throughout their stays to ensure they understand what to do at home, Bardetti says.

Teaming Up
In July 2010, the hospital teamed with Partners Home Care to pair heart failure patients with visiting nurses who come to their homes and closely monitor them with a defined protocol, Bardetti says.

RNs also keep track of discharged heart failure patients through telemonitoring, which allows nurses to monitor vital signs from an office while the patients are at home. Patients also receive follow-up calls within a week of their discharge, a program started about nine months ago.

“It’s very eye opening to hear what patients are saying when they get home,” Bardetti says. “You get a sense of how they’re doing at home. We’re giving you all this information to take home. We’re finding the discharge phone calls highlight and review that information.”

A hospital-based Heart Failure Clinic that allows heart failure patients to receive treatment on an outpatient basis also is helping to reduce readmissions, Bardetti says.

Nurses also make sure patients have a designated support person identified on admission available during their recovery, whether it is family, a neighbor or friend who can assist with discharge instructions and care. For patients who have trouble pursuing follow-up care because of finances, transportation issues or living alone, Newton-Wellesley provides nurse case managers.


Geneva Slupski is a member of the editorial team at Nursing Spectrum.