Incorporating community health nurses to follow patients with a moderate to high risk of readmission post-discharge could improve the risk of readmission for these patients. When a patient is discharged from the hospital, they can become overwhelmed and not be adequately prepared to go home despite the discharge education given (Kenney-Lueptow, 2020). Telephone follow up is a low-cost way to decrease readmissions and provide continued education to the patients (Heitkam, 2019). Utilizing the bedside nurses that have been caring for the patients in the hospital can create a greater sense of community for the hospital and its population. By connecting with patients post-discharge, nurses can also identify patient barriers to follow up, medications or inpatient education.

The process includes having bedside nurses call patients with at least a moderate risk of readmission based on their readmission risk score generated by the electronic medical record. They will call the patients to ensure that the patients are getting their medications, going to their follow up appointments and answering any questions the patient may have. The nurses will be able to pick patients based on connections that have been made with the patient throughout their hospital stay. This will help to create a relationship between the hospital and the community. Decreasing readmissions is beneficial to the hospital by decreasing its costs.

Date of publication

Spring 4-27-2020

Document Type

MSN Capstone Project



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