The Important Role Nurses Play in Care Transition and Reducing Readmissions

Hospital readmissions cost around $26 billion annually.1 Nurses are at the frontline of transitioning patients who need follow-up attention and treatment. If hospital leadership can help improve nurses’ lives and processes, it might make a dent in reducing hospital readmission rates.

In its simplest form, “care transition” is defined as a hospital discharge or movement from one care setting to another. The risk that readmissions pose to patient safety requires transitional care processes which are under constant evaluation for the patient experience. 

Nurses must navigate clinical communication and coordination of patient care, and they are best equipped to coordinate a successful transition. The bedside nurse, for example, may understand more about the patient’s needs as they travel through the care continuum than other care team members. And when those needs are communicated effectively, the nurse is given the opportunity to extend high-value care to the patient.

Nurses create transitional care plans by compiling all the pertinent patient information in the EHR and creating instructions to be followed. Then they collaborate and share the plan in detail with all members of the new care team. This ensures the handoff is seamless for both the patient and the new unit or facility.

The most important factor in transition care is communication during and after this handoff process.

What to Communicate and When

The goal of the handoff is to safely transfer the patient from one care setting to another by exchanging the necessary information with, and by effectively transferring the responsibility of care to, either a new care team or the patient’s family. With their family members involved, it’s important to keep them informed and updated along the patient journey.

It’s a lot to put on any nurse’s plate, but by standardizing and implementing an effective and comprehensive transition communication process, nurses can elevate patient safety, avoid adverse events that lead to costly readmissions, and decrease patient anxiety during the transfer process.

It’s important to remember that the transfer process doesn’t apply only to moving a patient from an acute setting to the home or a post-acute environment. There are many different handoff scenarios within the same organization, unit, and floor that need your close attention.

For example, nurses should be prepared to provide handoff communication:

  • At shift change
  • During a break
  • When patients are transferred within the hospital (e.g., from the ER to ICU, from radiology to the OR, etc.)

It’s extremely important for the purposes of continuity of care that the communication between the nurse and new team of clinicians or family prepares them for next steps. Then they’re able to anticipate the patient’s needs and make timely decisions.

At a high level, to adequately prepare the new care team, the following should be included in the handoff communication:

  • Patient care instructions
  • Treatment description
  • Medication history
  • Services received
  • Any recent or anticipated changes

More specifically, and in the case of transfers to a new care team or facility, an effective care transition communication plan will include:

  • Patient’s name and age
  • Reason for admission
  • Pertinent co-morbidities
  • Code status
  • Current isolation or precautions
  • Elopement risk
  • Lab results—including any pending and/or abnormal findings
  • Relevant diagnostic studies
  • Fall risk assessment
  • Any assessment findings that are appropriate to the patient’s current health

The receiving team of nurses frequently care for patients who lack pertinent health data.

For example, EKG results are often left out of the transition communication between hospitals and subacute rehabilitation facilities. In this case, if a patient has an episode of chest pain, the receiving team could conduct an EKG on their own, but without prior results to compare with, they can’t successfully rule out something dangerous, such as angina. So, they may err on the side of patient safety and send the patient back to the hospital, resulting in a readmission. However, if an EKG result is included in the transition communication, the receiving team can conduct an EKG on their own, compare the results with the EKG performed at the hospital, and determine whether there is an emergent need for a readmission or the issue is something they can safely handle in their own setting.

Pay Extra Close Attention to Medication Communications

While including all pertinent test results in the handoff communication is extremely important, there’s another area that needs special attention, because it causes more admissions than any other factor: medication.

It’s estimated that 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Communicating medication details is an area that poses the greatest risk for error as well as the greatest opportunity to effect a positive outcome. In fact, over 66% of emergency readmissions for patients over 65 years old are due to adverse medication events.

Breaches in handoff, such as failure to include specific details of the patient’s medication history and future dosage needs, have dire consequences. Defective handoffs are known to cause problems beyond adverse events. Issues such as delays in care, inappropriate treatment, and increased length of stay arise when transition communication is not strategically planned and delivered.

There are many root causes of a defective handoff, but since nurses play the most important role in the transition communication process, you must strategically develop and communicate the transitional care plan—not only by considering what information you believe should be communicated, but by extending a dialogue to the receiving team and understanding what information they feel is necessary to provide the best follow-up care possible.

Park Nicollet Methodist Hospital was able to cut readmission costs by 32% with provider-to-patient texting, improving their follow-up care. Read the full case study.

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  1. The Economic & Emotional Cost of Hospital Readmissions. (2021, April 1). HealthStream. https://www.healthstream.com/resource/blog/the-economic-emotional-cost-of-hospital-readmissions