D117 phase 2

D117 phase 2

Student Name

Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name:

Date

GoReact Video Reflection

Overview of the Video Reflection

This GoReact video reflection corresponds to Phase II of course D117 and focuses on factors contributing to patient readmissions following hospital discharge. A review of current, peer-reviewed literature was conducted to better understand the multifactorial causes of hospital readmissions and to identify strategies that healthcare providers can implement to reduce avoidable readmissions. The findings emphasize that readmissions are rarely the result of a single issue but are instead influenced by a combination of socioeconomic, clinical, and systemic factors.

What Are the Primary Causes of Patient Readmissions?

The literature consistently identifies several barriers that significantly increase the likelihood of hospital readmission. Patients with low income, limited educational attainment, language barriers, and higher body mass index (BMI) are at greater risk. Additionally, individuals living with multiple comorbidities experience higher readmission rates due to the complexity of managing chronic conditions. These factors often intersect, compounding challenges related to health literacy, access to care, and adherence to post-discharge instructions. Research demonstrates that patients affected by social determinants of health experience disproportionately higher readmission rates compared to more resourced populations.

Role of Patient Education and Communication

Effective patient education is a critical intervention in reducing readmissions. Providers must deliver discharge instructions using clear, patient-centered language that aligns with the patient’s level of understanding, preferred language, and cultural background. Education should not be limited to verbal instruction; written materials and teach-back methods should be utilized to confirm comprehension. Follow-up appointments must be clearly explained, including the purpose of the visit and potential consequences of non-attendance. Evidence suggests that patients who understand their care plan are more likely to adhere to treatment recommendations and less likely to require readmission.

How Can Transportation and Support Systems Impact Readmissions?

Access to reliable transportation is a well-documented barrier to post-discharge care. Patients who are unable to attend follow-up appointments due to transportation limitations are at increased risk for complications and subsequent readmission. Healthcare organizations should proactively assess transportation needs prior to discharge and coordinate hospital-based or community transportation services when necessary. Equally important is the presence of a post-discharge support system. Patients without family or caregiver support often struggle with medication management, activities of daily living, and symptom monitoring. In such cases, referral to home health services can provide essential clinical oversight and support during the transition from hospital to home.

Risk Factors and Interventions Related to Readmission

Importance of Standardized Discharge Protocols

Research supports the implementation of structured discharge protocols to guide interdisciplinary healthcare teams during the discharge process. These protocols serve as standardized frameworks that ensure critical components—such as medication reconciliation, follow-up scheduling, patient education, and risk assessment—are consistently addressed. However, while standardization improves quality and safety, discharge planning must remain individualized. Providers should tailor interventions to each patient’s unique clinical and social circumstances rather than applying a one-size-fits-all approach.

Patient-Specific Risk Assessment

For the patient discussed in this reflection, the most significant risk factors for readmission include the absence of a post-discharge support system and limited financial resources. The inability to afford reliable transportation poses a substantial barrier to attending follow-up appointments and accessing ongoing care. Without appropriate intervention, these factors significantly increase the likelihood of preventable readmission.

Provider Responsibility in Preventing Readmissions

From a provider perspective, identifying and addressing these risks prior to discharge is essential. Comprehensive discharge planning should include collaboration with case management, social work, and community-based resources to mitigate barriers. By proactively addressing social determinants of health, ensuring continuity of care, and providing individualized support, healthcare providers can play a critical role in reducing readmissions and improving patient outcomes.

References

Agency for Healthcare Research and Quality. (2023). Re-engineered discharge (RED) toolkit. https://www.ahrq.gov

Centers for Disease Control and Prevention. (2022). Social determinants of health and health equity. https://www.cdc.gov

Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., & Curtis, L. H. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA, 303(17), 1716–1722. https://doi.org/10.1001/jama.2010.533

McCarthy, D., Johnson, M. B., & Audet, A. M. J. (2013). Recasting readmissions by placing the hospital role in community context. Journal of the American Medical Association, 309(4), 351–352. https://doi.org/10.1001/jama.2012.241435