Bridging the Gap Between Hospital Discharge and Community

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Readmissions to the hospital has been projected to cost the U.S. approximately 17 billion dollars annually, of which 90% of those readmitted were unplanned (Weiss, Yakusheva, and Bobay, 2011). For those patients who have a primary care provider and actually follow up as instructed within 1-2 weeks, 2/3 of those primary care providers will have not received a written discharge summary of the patient’s stay. On the other hand, a large percentage of patients either do not have access to primary care and if they do, they fail to follow up within 1-2 weeks after hospital discharge as instructed. This may may be the cause of a number of different loopholes, the biggest of which is inadequate communication and education. The quality committee has worked closely with the hospital’s team of physicians and other providers as well as all nursing departments, ancillary department’s and all relevant nonclinical staff to propose the funding of a department, staffed by experienced registered nurses, who will be the key players responsible of bridging the gap between hospital and community providing discharge instructions, education and will follow the patient in the weeks coming after they leave the hospital ensuring access to medications and appropriate follow ups. The purpose of this program is to significantly reduce the number of readmissions that are related to ineffective discharge planning and/or poor education. The transition team will consult on every admitted patient in the hospital to assess their ability to effectively transition into the community setting after discharge. Those who have adequate resources, established relationships with primary care, and do not require any social work assistance, the team will still provide a comprehensive discharge planning evaluation, education, and an evaluation of their understanding of the steps to take as soon as they leave our building. Each patient will be given a score based on his or her evaluation that will be...
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