“I think poor discharge planning is that top contributor [to readmission]. And by that, I mean discharge planning that doesn’t assess a patient’s educational level, their support at home, what resources they have, like transportation and finances, and then to go further, evaluating if the patient even understand the reason they were admitted and then how to manage their care once they leave. There’s only so much we can treat in the hospital. what happens at home is what we need to prepare our patients for,” Stephanie Frost, MN, RN, OCN®, manager of outpatient clinics at City of Hope Cancer Center Chicago in Illinois, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a conversation about preventing hospital readmissions in patients with cancer.

Music Credit: “Fireflies and Stardust” by Kevin MacLeod

Licensed under Creative Commons by Attribution 3.0 

The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Learning outcome: Learners will report an increase in knowledge related to nursing strategies to reduce readmission rates for patients with cancer.

Episode Notes

• The NCPD activity for this episode has expired, but you can still earn NCPD through many other ONS Podcast episodes. Find a full list of opportunities.
• Oncology Nursing Podcast episodes:
  • Cancer Symptom Management Basics series
  • Episode 193: How Social Determinants of Health Affect Cardio-Oncology Survivorship
  • Episode 107: Social Determinants Lead to Unequal Access to Health Care
• ONS Congress® presentations:
  • Implementing Continuous Care Program and Streamlined Care Team Communication to Reduce Hospital Readmission and Emergency Department Visits (coauthored by Stephanie Frost)
  • Improving Readmission Rates Through Transitional Care Management for Oncology Patients at Highest Risk for Readmission
• ONS Voice articles:
  • Cross-Discipline Cancer Care: Oncology Nurses Share Specialized Knowledge With Non-Oncology Settings
  • Postdischarge ICI Patient Education Eliminates Hospital Readmissions
  • Symptom Management Strategies You May Not Be Using
  • Transitions in Care: Communication Builds a Bridge of Consistent Support for Patients
• ONS books:
  • Oncology Nurse Navigation: Delivering Patient-Centered Care Across the Continuum (second edition)
  • Telephone Triage for Oncology Nurses (third edition)
• ONS courses: Treatment and Symptom Management—Oncology RN
• Clinical Journal of Oncology Nursing articles:
  • Decreasing Readmission Rates in Patients With Immune-Mediated Toxicities Using an APRN-Led Discharge Teaching Program
  • Patient Handoff Processes: Implementation and Effects of Bedside Handoffs, the Teach-Back Method, and Discharge Bundles on an Inpatient Oncology Unit
• Oncology Nursing Forum articles:
  • Predictors of Unplanned Hospitalizations in Patients With Nonmetastatic Lung Cancer During Chemotherapy
  • Systematic Review of Hospital Readmissions Among Patients With Cancer in the United States
• ONS Huddle Card: Handoff Communication
• ONS Guidelines™ and Symptom Interventions
• Healthy People 2030: Social Determinants of Health
• Journal of the Advanced Practitioner in Oncology article: Uncovering and Addressing Implicit Bias in Oncology

To discuss the information in this episode with other oncology nurses, visit the ONS Communities.

To find resources for creating an Oncology Nursing Podcast™ Club in your chapter or nursing community, visit the ONS Podcast Library.

To provide feedback or otherwise reach ONS about the podcast, email [email protected].

Highlights From This Episode

“Of course readmissions are inevitable, but ultimately, high rates may indicate that there’s a problem. Something is wrong. The quality of our care is not up to par. So looking at the rate of unplanned readmissions encourages hospitals to look inward, to see what’s going on, and find the gaps.” TS 2:31

“The number one thing we can do is review the patient’s social determinants of health. We’re seeing this assessment tool used more and more in the hospital system, and it can truly help identify high-risk patients. … But it really takes into consideration a patient’s environment, and it includes five components—access and quality of education, economic stability, healthcare access and quality, home environment, and then the patient’s community.” TS 5:17

“Recently, we had a patient that was seen in our ED [emergency department] for nausea and vomiting. And then due to that follow-up call the nurse made, she was able to get another set of labs drawn on the patient, found that they had an electrolyte imbalance, and then got the patient set up for fluids in an outpatient setting. So I think that really prevented that patient from going back to the ED, probably for the same reason they were there in the first place.” TS 18:00

“When we reviewed the data, we saw our readmission rates had dropped by 51% at the six-month mark, and same with our ED visit rates. And then our referrals to the continuous care team jumped 155%. … But we were able to discover some other opportunities through the process. So for example, through the chart audits completed, we were able to identify an increased need for our pain management services. There was a large number of patients that the reason for visit was pain, so we ended up expanding our templates for our pain management providers to meet that need and ultimately reduced the admissions for pain.” TS 22:38