How to prevent hospital readmission: Intensive primary care


It is estimated that one fourth to one third of patients transitioning in care will be re-hospitalized within 30 days due to preventable complications. The following risk factors have been identified as increasing the risk of hospital readmission within the first 30 days. The more risk factors the greater the likelihood the patient would benefit from a formal a transitional care plan and intensive primary care.

  • Age 80 or older
  • Moderate to severe functional deficits
  • An active behavioral and/or psychiatric health issue (diagnosed or not : most patients have not had a psychiatric evaluation)
  • Four or more active co-existing health conditions
  • Six or more prescribed medications (includes vitamins, supplements, and occasional pain medications)
  • Two or more hospitalizations within the past 6 months
  • A hospitalization within the past 30 days
  • Inadequate support system
  • Low health literacy
  • Documented history of non-adherence to the therapeutic regimen

Older adults are often hospitalized for a newly diagnosed condition or an exacerbation of a chronic condition. They are at an increased risk of re-hospitalization due to poorly managed transitions from home to hospital, and from hospital to home or other care settings.  Further complicating this situation is the condition of delirium which can be caused by a change in environment. Delirium can take several weeks to clear up particularly in an elderly patient with many medical problems. For older patients with multiple chronic conditions this “transition in care” is a point of great vulnerability along the continuum of care where many errors of omission and commission can occur.

The intensive primary care model is a patient-centered; nurse practitioner led interdisciplinary process that begins with an initial assessment of the patient’s potential needs prior to discharge. The primary aim is to help keep the patient at home safely. Patients are seen consistently and preventive to help detect subtle changes in condition that could result in a hospital admission. The nurse practitioner will attempt to streamline the medications that may be causing adverse effects leading to a decline in function. Intensive primary care is best suited for patients with multiple medical problems and or psychiatric co-morbidities that maybe increasing the risk of emergency room utilization. Emergency room utilization increases the risk of hospital admission in elderly people.

When a patient requires a transition of care from the hospital to home ongoing communication with the patient’s hospital care team and prospective care coordinator (loved one or professional care manager) help ensure a successful care transition while reducing the risk of readmission.

What should you expect from an intensive primary care evaluation?

In planning for a transition in care the patient’s medical record is reviewed and an assessment of the medical condition, and functional, social, cognitive capabilities is conducted to help assures that the comprehensive needs of the patient can be addressed. The patients, family member (professional care manager) are included in the process to help everyone understand and feel comfortable with the intended plan of care.  The process concludes with the coordination and implementation of services and transition to the patient’s home.

Intensive primary care does not require the patient be admitted to a hospital. Patients, family members, care managers can request the evaluation if they feel the medical condition is becoming increasingly complex. A good indicator that the condition is becoming increasingly complex:

  • Being prescribed increased amounts of medications
  • Being referred to numerous specialists
  • Being advised to have many diagnostic tests
  • You have had to utilize the emergency room more frequently
  •  You have been readmitted to the hospital more than once in the last 6 months.

If have a family member or are the care manager for a patient who has had to transition in care what lessons have you learned, and what advice would you pass on? Please share your comments so that together we can help each other.

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