A Team That Plays to Win-Win

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Patient Education Reduces Readmissions

by Rebecca Proch

For patients like Margeret Rukstelis, the chances of being readmitted are greatly reduced, thanks to Alan Skiles.

IOm Recommendation 7

Evan Metcalf bought himself a blood pressure/oxygen monitor and a scale because of his nurses in the Johns Hopkins Bayview Medical Center’s Progressive Care Unit (PCU). His six-week period of home care, prescribed following a week at Hopkins Bayview for treatment of chronic obstructive pulmonary disease (COPD), had come to an end—but he’d learned from his nurses that his self-managed care needed to continue.

“I want to keep track of those things for myself, too,” he says. “When I can see that my numbers are off, I can call my doctor and he can give me adjustments so I don’t have to go right back to the hospital.”

For patients like Metcalf (whose name has been changed here to protect his privacy) readmissions for conditions such as chronic heart failure, pneumonia, or COPD, readmissions are often both likely and preventable. The transitions among hospital, home, and outpatient care are crossroad moments, where many factors such as communication among providers, family support, and especially patient education can have a tremendous impact on the likelihood of readmission.

To improve patient-centered care and decrease unnecessary re-hospitalizations, Johns Hopkins Health Systems launched a Transitions of Care (TOC) initiative in April 2011 that described seven strategies to reduce admissions. Each hospital was tasked with choosing a pilot unit to test and incorporate individual strategies before implementing them system-wide. At Johns Hopkins Bayview, the PCU nursing staff took on the patient and family education strategy.

“Change is hard,” acknowledges Elaine Gittings, MS, RN, the unit’s Patient Care Manager. “You might be asking a nurse who’s been doing patient education for 20 years to try a whole new method. “

As part of the testing, the PCU team identified risks—including those in the home and social issues such

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