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Despite the intention to create high-quality care services for patients of all ages, some situations require additional attention and research. Each group of people has specific reasons and conditions under which they need professional help. However, when a person has already used a particular healthcare service and then returns to a hospital, this event must be analyzed to identify and prevent the risk of readmission. The elderly who wants to maintain their independence at home as long as possible is the chosen local community. Readmission in older adults within 30 days after discharge remains a serious event in nursing practice, and congestive heart failure (CHF) or other chronic diseases are common causes of hospitalization (Nair et al., 2020). Nurses should develop a plan for reducing and predicting readmissions by improving transitional care, promoting regular follow-ups, and enhancing patient education.
The first step in the offered plan to prevent hospital readmissions among the elderly is related to improved transitional care. The main idea is to ensure “coordination and continuity” of health and nursing care for patients and their families to understand their treatment goals (The National Transitions of Care Coalition, as cited in Ortiz, 2019, p. 73). CHF and other serious chronic conditions require specific environments to identify red flag alerts quickly. When older patients go home, they should never forget self-identified care goals (Nair et al., 2020). Nurses have to explain basic self-management skills and check how patients understand and follow these recommendations. Thus, following transitional care principles is critical to the prevention plan.
Another element of preventing or reducing hospital readmissions is encouraging follow-up visits. Patient engagement plays an important role in maintaining their well-being because nurses get a chance to identify current risks and problems without disturbing the desired independence of patients in their homes. Follow-ups can be implemented in a variety of ways, including discharge planning, telephone communication, and medication reconciliation (Ortiz, 2019). According to Nair et al. (2020), early post-discharge follow-up is a good step to prevent readmissions and health complications. Nurses must explain the worth of this strategy to patients and their families in a clear and comprehensible way.
Finally, regardless of the level of patient knowledge and readiness to cooperate, nurses are responsible for patient education. Preventing interventions are impossible without patient education which should start during the initial hospitalization and continue during follow-ups (Nair et al., 2020). Nurses regularly ask patients about their dietary habits, medications, and even water intake to cover gaps in care. Education is related not only to a particular health condition but to overall preferred lifestyles. When older patients realize the worth of their participation in care processes, their pursuits for independence increase. Nurses, in their turn, achieve the purpose of readmission reduction and prevention.
In conclusion, aging is associated with different health changes and obligations among nurses and patients. The goal of this assignment was to develop a plan to reduce and prevent hospital readmissions among the elderly. The major characteristics of the chosen community are the desire to be independent and state in their homes as long as possible. Thus, readmission is not only an administrative risk for nurses and other healthcare providers but a kind of personal inconvenience for patients. Readmission intervention consists of transitional care, follow-ups, and patient education. If nurses consider these simple but obligatory rules, they can help older patients improve their self-care at home and reduce the risk of readmission after discharge.
References
Nair, R., Lak, H., Hasan, S., Gunasekaran, D., Babar, A., & Gopalakrishna, K. V. (2020). Reducing all-cause 30-day hospital readmissions for patients presenting with acute heart failure exacerbations: A quality improvement initiative. Cureus, 12(3). Web.
Ortiz, M. R. (2019). Transitional care: Nursing knowledge and policy implications. Nursing Science Quarterly, 32(1), 73-77. Web.
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