Nurse kneels and talks with lady in wheelchair

Reducing hospital re-admissions: Nurse oversight

May 22, 2023
Lori Kewalram


Welcome back home ! We all know how great it feels to sleep in our own beds. To be surrounded by our own pictures. To know where everything is. To operate on our own schedule. While great medical care helps with recovery from acute health conditions, no hospital setting can match the comfort of being home.  
But we know that in California, more than 1 in 10 patients will return back to hospital within 30 days. This is called the unplanned readmission rate. California and the entire health community is working hard to reduce this rate because it costs the economy $25 billion on preventable readmission.  
However, here at BrightStar of Huntington Beach, we are less concerned about the economic impact on the state and more concerned about the emotional impact on the patient. It's an incredibly frustrating experience for the patient to have to GO BACK to hospital after being discharged.  
Can you imagine how it must feel? If you or your loved one has to return to hospital for an unplanned readmission? They get better, the excitement builds as discharge nears, they get home, they try to settle back into a routine - and within 30 days they're back in a sterile environment, unable to exercise control over their surroundings. We know how frustrating this can be from talking to the patients who are under our care in their own homes.  
This is why we are dedicated to working with the entire medical community to prevent unplanned hospital readmissions.  

Here is how we approach this important aim in the continuum of care for our patients / clients:  
  • Registered Nurse visit before start of care. Our RN Case Manager meets with the patient and family BEFORE we start care, regardless of whether or not medical (skilled) care is required.  
  • Customized Plan of Care. At this visit, our RN conducts a full personal and home assessment in order to develop a detailed, customized Plan of Care.  
  • Discharge orders reviewed by RN Case Manager. When someone under our care returns from a hospital visit, our RN Case Manager reviews the Discharge Orders so that continuity of care is maintained, medications are taken correctly and other care aspects from the hospital or Skilled Nursing facility are incorporated. In our own experience, this is the single biggest aid in preventing unplanned readmissions.  
  • RN oversight over every caregiver. Every customer's case file is continuously reviewed by the RN Case Manager on our staff, whether or not the care we are delivering is medical in nature. We do this as a matter of course. Our operating procedures and brand values have required this for decades.  
  • Care staff are coached on each Plan of Care. Our RN Case Manager or Client Care Manager coaches the caregiver to ensure that communication is maintained and our client patients receive the care they need to reduce the risk of them going back to hospital / skilled nursing facility.

We think this is the best way to help the healthcare ecosystem reduce unplanned hospital re-admissions. In our view, the home is always the best place to get better.
(Image used in this blog post is courtesy of Unsplash+ )