The Role of Nurses’ Patient Education in Reducing Frequent Hospital Readmission of Hypertensive Patients in VA Hospitals
Hospital readmissions among hypertensive older patients have become rampant in recent years, which increases healthcare cost as well as exalts pressure on the current healthcare system. The purpose for this inquiry is to determine the important role that nurses’ patient education plays in reducing frequent hospital readmissions of hypertensive patients in veteran administration hospitals. The scope of this inquiry will include gathering sufficient background evidence that confirms the existence of the problem as well as conduct a literature synthesis to establish what other scholars have documented about various educational intervention approaches. Control trails and secondary analysis will be employed in this inquiry to effectively synthesis available literature that is related to the topic. Scholarly evidence supports the role of nurse-guided teach back sessions, educative interventions in understanding educational materials and educational follow ups in reducing frequent hospital readmissions. A pilot intervention to test applicability of these interventions in veteran hospital will be employed to determine if they can effectively reduce hospital readmissions among hypertensive patients aged forty years and above.
Among hypertensive patients aged forty years and above, what is the role of nurses’-patient educational intervention in comparison to standard care offered during hospitalization in reducing frequent hospital readmission within a period six months?
Hospital readmissions among hypertensive patients are continually being frequent within thirty days after the initial discharge, which increases financial costs and severe pressure on the current healthcare system. Among the Medicare beneficiaries, one in every five-hypertensive patients, which is equivalent 19.6% of all patients, is being readmitted to the hospital within thirty days after their initial discharge. This has raised concern as it accounts for more than fifteen billion dollars in healthcare spending (Baptiste, 2014). Reducing frequent hospital readmissions is one of the quality priorities posed both at the institutional and national level to help enhance efficacy of inpatient and outpatient care. This is because unplanned hospital readmission attributes to poor quality care among the hospitalized patients as well as inefficient transmission from home to the hospital. As noted by McHugh (2013) Medicare currently withholds financial supports to hospitals for patients readmitted within twenty-four hours for the same ailment. Forecasts further indicate that Medicare may soon withhold funds to hospitals that report the highest rate of readmissions occurring within thirty days after the initial discharge. While hospital readmissions among hypertensive patients have raised concern among other additional stakeholders, there is a possibility to arouse the presidential budget consideration as a way to reduce medical cost within the wider healthcare system.
The need to reduce hypertensive patients’ readmissions in the veteran administration hospitals has particularly drawn attention as they benefit from an inherently distinct payer system that demands for greater medical support. Although other clinical issues including risk factors like age and comorbodities may also attribute cases of hospital readmission, statistics indicate that readmissions among hypertensive patients remain relatively high in these hospitals despite the significant efforts to improve the quality of care delivery. This has in return subjected most veteran administration hospitals to severe Medicare penalties as they report the highest number of readmissions of hypertensive patients within thirty days following their initial discharge. A report compiled by Baptiste (2014) indicates that hospital readmissions among the hypertensive patients are rampant among adults aged forty years and above than among younger people. These variations may not only be attributed to physiologic factors that include hypercoagulability but they can as well be linked to behavioral factors that include poor nutritional and lifestyle patterns, noncompliance to medication, oversensitivity to somatoform symptoms and failure to adherence to follow-up and self-care. As explained by Mudge (2011) over 75% of all hospital readmissions for hypertensive patients can be prevented if proper nurse-patient educational interventions are employed to help curb the negative behavioral issues that contribute to heightened severity of the problem. Although the effectiveness of such interventions can significantly vary depending on a patient’s ability to comply and degree of disease severity, experts report that a tailored innovative education approach by a qualified nurse can be more effective in reducing hospital readmission compared to the standard care offered during hospitalization. (McHugh, 2013). The possible areas that such interventions can help to address include proper nutrition, self-monitoring, lifestyle modification and medication adherence. Success in such interventions can be promoted particularly when patients are engaged in training sessions during hospitalization and discharge and when they integrate into the community. In order to effectively address the current clinical issue, inquiry can be guided by a PICOT question that integrates the population of interest, intervention to the clinical issue, comparison to alternative intervention, expected outcome and the overall amount of time intended for the intervention to help achieve the expected outcome. In this study, PICOT will represent:
P- Hospitalized VA patients diagnosed with hypertension. This will ensure that the study focuses on one type of ailment with a manageable sample size to allow for a consistent method of intervention.
I- role of inpatient nurses in providing patient education as an intervention measure to cut down re-admission rate among hypertensive patients.
C- 6W versus 6E patients.
O-reducing frequent hospital readmissions
The PICOT question for the inquiry is: among the hypertensive patients aged forty years and above (P), what is the role of an innovative-tailored nurse-patient education (I) in comparison to the standard care offered during hospitalization (C) in reducing frequent hospital readmission in veteran administration hospitals (O) within a period of six months (T)?
Multiple sources will be analyzed to gather sufficient evidence to develop a reliable intervention for practice change and subsequently promote intervention for the current clinical issue. Articles to be included in this synthesis will be chosen on basis of their relevance to the reduction of hospital readmission among hypertensive patients in veteran administration hospitals. Although a wide range of articles will be reviewed, majority of them will be eliminated particularly if they are more than ten years old, are based on a relatively small population sample, do not provide a reliable level of evidence or do not meet the proposed search criteria. An extensive review of suitable literature will be derived from various databases that will include MEDLINE, EbscoHost, PubMed and CINAHL. The key words that will be used in this search will include hypertension, hypertensive patients, nurse-patient education, readmission, thirty-day readmission rate, veterans, and reducing hospital readmissions.
Hypertension is a serious clinical issue that attributes to high rates of mortality and morbidity among older patients. While quality of healthcare has continually been enhanced to curb these implications, frequent hospital readmissions have become a primary issue of concern in most veteran hospitals. Although patients’ blood pressure in these hospitals is usually optimized before hypertensive patients are discharged, a growing challenge is how to maintain this pressure at optimal level after patients leaving the hospital environment. The aim for this synthesis is to establish what other scholars have documented pertaining to the role of nurses’-patient education in reducing hospital readmission among older hypertensive patients. This will enhance the establishment of a potentially effective intervention approach that can help to reduce cases of hospital readmission among older hypertensive patients in veteran administration hospitals within thirty days after the initial discharge.
Allaudeen (2011) conducted a random controlled trail among hypertensive patients that were being discharged from the UC San Francisco hospital to determine whether nurses’-patient educational intervention programs had any beneficial impact in reducing frequent hospital readmissions. The population sample participating in this study included 700-hypertensive adults aged forty years and above. The patients were divided into two groups that included a study group that would be involved in “before, during and after-discharge” educational interventions and another control group that did not participate in “before, during and after-discharge” intervention sessions. While the two groups had been given the standard care during the hospitalization period, the study group was allowed to participate in “before, during and after-discharge” educational interventions in addition to the standard care. The study group was first engaged in a sensitization session on self-management by a qualified registered nurse during hospitalization. Refresher sessions were offered during discharge and patients were encouraged to ask questions relating to the topics taught before leaving the hospital. Upon discharge into the community, the registered nurse conducted follow-ups through making telephone calls to each patient after every two days to remind them about the learnt skills on self-management. The nurse particularly reminded the patients in the study group about the vital hypertensive symptoms, how to maintain their blood pressure at optimal level, when they could call a healthcare provider as well as when they could go to the hospital. This was however not applied to the control group, and as such, members of this group only benefited from the standard care provided during hospitalization. Based on data gathered in the hospital, the researcher assessed the number of patient readmissions after thirty, ninety and 180 days following the initial discharge. Findings of the research showed that hospital readmissions in the intervention group had dropped to 15% at thirty days after the initial discharge. Patients in the control group however indicated a higher readmission percentage, which was estimated at 68% after the initial discharge. Allaudeen thus concluded that educational intervention on self-management during hospitalization and discharge and subsequent telephone follow-ups by a qualified nurse significantly reduced the rate of hospital readmission among older hypertensive patients.
A study by Krumholz (2012) included a secondary analysis of previous control trials to determine whether the teach-back educational interventions offered to patients by qualified nurses can reduce frequent hospital readmission among older hypertensive patients. The analysis was based on an educational inquiry that had been carried out at the Washington Medical Center. The inquiry included two hundred high-risk hypertensive patients aged between forty and sixty five years. The patients took part in one-hour teach-back sessions offered by registered nurses within a six-month period. Prior to this intervention, the hospital reported an average of 18% hospital readmissions among hypertensive older patients within thirty days after their first discharge. The main goal for the intervention was to reduce readmissions rates occurring within thirty days to 13.8% for older hypertensive patients discharged from the hospital during the study period. The learning sessions started two days after the day of admission to allow the patients to settle down and recover from illness-based stress. During hospitalization, the participants were taught how they can effectively manage their hypertensive condition outside the hospital setting. The various topics that were taught included causes and symptoms of hypertension, proper nutrition, weight management, daily self-management activities, family support and adherence to medication. The findings of this analysis showed most patients had changed their behavior following the intervention, which in return reduced frequent hospital readmissions. Krumholz thus concluded that the teach-back educational sessions offered during hospitalization were effective in reducing frequent readmissions as nurses had more time to emphasize on the self-management topics that the patients did not fully understand.
Another inquiry conducted by Mudge (2011) was intended to establish the important role that nurses’-patient education during hospitalization, discharge and while in the community play in promoting strong partnership between medical professionals and the patient. This is because such partnerships would ensure that the patient’s needs in relation to self-management are met, which would in return reduce frequent hospital readmissions. This inquiry sampled all licensed nurses serving hypertensive patients in 200 hospitals in California and New Jersey. It mainly aimed to establish the important role that personalized skills given to each patient during hospitalization, discharge and in the community played in enhancing compliance with instructions given by nutritionists, clinical doctors, pharmacists and physical therapists pertaining to proper nutrition, weight management and medication. To achieve this objective, hospital based licensed nurses were allowed to help hospitalized patients to fully understand the various educational materials obtained from these professionals. This was achieved through interpreting the materials in a layman’s language particularly to patients that may have proven to have a lower understanding capacity. Refresher sessions were offered during discharge to remind patients about the important self-management skills learnt during hospitalization and give them an opportunity to ask questions before leaving the hospital. Conversely, community based licensed nurses were equally important in equipping the patients with out-of-hospital self-management skills during follow-up. The various topics that the community based nurses covered included routine self-monitoring and medication reconciliation. They also linked the patients to the various professionals to obtain any assistance and responses to inquiries that they had recorded in their dairy diaries. This promoted collaboration between the patients and medical professionals, which in return encouraged positive behaviors. The results of patients in the study group were compared to those obtained from patients in another control group. This group had only benefited from the standard care given during hospitalization and did not receive any educational intervention from hospital based or community based licensed nurses. Findings of the study showed that there was a significant decline in hospital readmission within thirty days after the initial discharge among patients in the study group but not in the control group. Mudge thus concluded that nurses’-patient educational intervention in promoting positive collaboration between hypertensive patients and various professionals was important in reducing frequent hospital readmission within thirty days after the initial discharge.
A study by Baptiste (2014) was intended to establish whether nurses’ role in educating patients how to utilize community resources reduced frequent hospital readmissions within thirty days after the initial discharge. The study sampled 800 patients that would be linked to local community resources to enhance quality care transition after being discharged into the community. To achieve this objective, registered nurses from the San Francisco Community Care Initiative indentified high-risk hypertensive patients aged forty years and above before they could be discharged from the hospital. During hospitalization, qualified nurses employed a coaching model to teach patients how they could manage their condition on their own after being discharged into the community. This included providing them with crucial tools that could help them to effectively organize as well as utilize their health information. They also provided patients with information on how they can access their medication as well as plan follow-ups within their primary healthcare provider. During discharge, refresher sessions on various topics taught during hospitalization were offered. Upon discharge into the community, nurses further conducted frequent home visits to render patients with post-discharge education sessions and ensure that their health needs were being met. The results of patients in the study group were compared to those of patients in a control group at the end of the exercise. Findings of the research showed that there was a significant decline in frequent hospital readmissions among patients that benefited from educational intervention provided by nurses on how they could utilize community resources to manage their hypertensive condition. This however was not the case with patients in the control group, as they did not obtain any educational information on how the community resources could effectively be utilized to help reduce frequent hospital readmissions. Baptiste thus concluded that nurses’-patient education played an important role in promoting efficient care transition, which in return reduced frequent hospital readmissions.
Synthesis of important literature has confirmed that nurses’-patient educational interventions are crucial in reducing frequent hospital readmissions among hypertensive patients. In order to recommend for the implementation of these interventions in veteran administration hospitals, a pilot intervention will be important to determine whether the change practice would be effective among older hypertensive patients aged forty years and above. The specific aim for this activity is to enhance the implementation of an innovative and effective nurse-driven educational intervention that incorporates the teach-back, coaching, educative interventions in self-management, follow-ups and collaborative partnership between patients and health professionals. The intervention will mainly target nutrition management, weight control, improved lifestyle, physical activities and compliance with medication. The setting for intended intervention will be a medium-sized veteran administration hospital situated in Midwest. This will however not limit the perspective of the intervention program as educational sessions will be offered at the hospital during hospitalization and discharge and in the community after the discharge. It is anticipated that the physician as well as the registered nurses serving in the facility will support the intervention particularly because it will supplement the state of the current healthcare for the high-risk population. There may be potential resistance from nurses due to perceived additional responsibilities to their daily activities. Explaining the ultimate benefit that this intervention might render will however trigger support as nurses will eventually be able to promote improved health outcomes, which would in return reduce overall burden of hospital readmissions.
Participants in this intervention will include all hypertensive patients in 6W admitted between March and May and are about to be discharged from the hospital. The patients must be AOx3 and ready to learn. All hypertensive patients in 6E will be used as a control sample, which means that they will not be engaged in various nurse-patient educational interventions. The selection criteria is based on previous data, which shows that the hospital admits over seven thousand hypertensive patients per year with 89% of these constituting of older patients aged forty years and above. This means that registered nurses serving in the hospital can be able to recruit a reasonable number of hypertensive patients aged forty years and above to participate in the exercise throughout the intervention period. Participants will however be recruited at a thirty-day interval to allow the nurses to evaluate cases of readmissions occurring thirty days after initial discharge of each group of patients. Registered nurses will be encouraged to explain the study process to eligible participants, which will include explaining the various assessments they would be required to take and the questions they would be needed to respond to.
The process of recruitment will begin by recording the name of the last hypertensive patients that come in between March and May. A review will then be conducted after two months to establish whether they have been readmitted for cardiac-related diagnosis. Clerks from 6W and 6E can be engaged at this stage to makes and track cardiovascular patients that may have been admitted in the designated time frame and whether they get readmitted within two months of discharge. Upon recruitment into the program, patients will have their dietary patterns, lifestyle patterns assessed, and their weight taken. Registered nurses will then begin the intervention process by giving educational materials containing important information relating to weight management, proper nutrition and lifestyle change to the hospitalized participants. Among the educational materials provided will include an interactive booklet titled “Hypertension Management”, which will be given to all patients diagnosed with hypertension. The various topics and mode of interaction contained in this book include:
Page 1. Explain what hypertension is. (Coloring)
Page 2. Explain what could cause hypertension. (Word search)
Page 3. Self monitoring (connect the dots)
Page 4. How to manage hypertension with medication (maze)
Page 5. How to manage hypertension with diet/DASH diet (coloring)
Page 6. How to manage hypertension with exercises and weight loss (fill-in-the-blank)
Page 7. How to reduce stress (cross word puzzle)
Page 8. Importance of following up with primary care providers, and keep appointments. (Connect the dots)
Page 9. Screen for diseases that hypertension can potentially lead to. (Word search)
Page 10. Live a quality life. MOVE program.(Coloring)
Educational intervention will be provided at this stage to ensure that the patients are able to understand the information contained in the materials. Patients will then be engaged in bedside teach back sessions where the nurses will brainstorm on various topics covered in the materials. During discharge, community nurses will visit the participants at the hospital to sensitize them about the available community resources and teach them how they can utilize these resources to effectively manage their condition through exploiting services of community-based physicians. Skills on quality self-management will also be provided, which will be inclined towards improved diet, positive lifestyle change, compliance with medication, weight control and participation in physical activities. Upon discharge from the hospital, community based nurses will conduct regular home visits where they will frequently provide refresher lessons on various topics covered. Educational follow-ups will also be provided to the participants in the community, and these will mainly include making consistent phone calls to inquire if there is any topic relating to self-management that patients did not understand and to remind patients about the various skills that they may have learnt during the intervention process. The process will be repeated throughout the intervention period to ensure that all recruited participants have been involved in the activity. Effectiveness of the intervention process will then be determined through establishing significant change in lifestyle pattern, type and frequency of nutrition and compliance with medication using nominal, ordinal and Morisky’s scales respectively. Self-reported assessment will also be used to measure any significant change in lifestyle pattern. Study participants will also be required to fill in questionnaires pertaining to lifestyle behaviors, exercise pattern, dietary intake and self-monitoring exercise. Long-term effectiveness of the intervention program can subsequently be evaluated through quarterly audits when patients come for normal check up at the hospital. Patients exhibiting noncompliance to the change practice will be retrained and empowered.
Sufficient evidence has proven that nurses’ education is important in reducing frequent hospital readmissions. All veteran hospitals should incorporate nurse-driven educational interventions to promote overall health outcomes. This should be incorporated with establishment of new policies that promote education intervention for hypertensive older patients.
Allaudeen, N. (2011). Redefining Readmission Risk Factors for General Medicine Patients, Journal of Hospital Medicine, 6(2):54-60.
Baptiste, D. (2014). A Nurse-Guided patient-Centered Hypertension education program, Journal of Nursing, 4(2): 41-57.
Krumholz, H. (2012). Randomized Trail of Education and Support Intervention to Prevent Hospital Readmission, Journal of Clinical Studies, 39(1):67-81.
McHugh, M. (2013). Hospital Nursing and 30-Day Readmissions Among Medicare Patients with Heart Failure, Myocardial Infarction and Pneumonia, Medicare, 51(1):51-77.
Mudge, A. (2011). Recurrent Readmissions in Medical Patients: A Prospective Study, Journal of Hospital Medicine, 6(2):61-67.
Rau, J. (2011). VA Experience Shows Patients Rebound Hard to Counter, Retrieved on 24th February, 2015 from http://kaiserhealthnews.org/news/va-readmissions/