Preventing Readmission: Everyday Support That Keeps Patients Home

Private records of patients who returned are maintained by nurses employed with discharge and community positions. Those who were not sick enough for anyone to do anything about, but those who were sick enough to be readmitted to the hospital because no one was there to notice that they had stopped taking their medications, or that the pressure area had become a wound because the repositioning was stopped when the family visit schedule changed for five days.

Read the notes on these readmissions and the surprising thing to note is that very little of what has gone wrong is clinical. Day to day life was what went wrong. That's why daily support should be part of the readmission dialogue. Most of what helps a recently discharged or chronically ill person not be in hospital is routine: adequate nutrition and fluids, good personal hygiene, mobility and safety, adherence to medication schedule, keeping follow-up appointments, and close supervision to notice change early. Support workers are precisely who is intended to deliver this territory, and nurses who know how to use them effectively provide an extra layer of protection that clinical brilliance at the bedside can't replace.

The Five Mundane Defences

Nutrition and hydration. Poor intake and loss of appetite account for disproportionately large numbers of avoidable deterioration, both of which are invisible in the 15-minute clinical visit. When a support worker prepares meals, serves them where appropriate and observes when the plate is empty, they are conducting a daily surveillance program on the number one failure point.

Skin, hygiene and continence. Personal care shifts also include observation shifts. The reddened heel and the skin tear are visible to a worker who is helping them shower, who is also the only person with the specific information to give.

Safe movement. The number of falls adds up to readmissions every day. The constant checking of the technique performed during transfers and during mobility, the consistency of the technique taught by the physiotherapist and the use of an additional pair of eyes on the loose mat and the lighting conditions, is falls prevention at its most practical and effective.

Medication routine. As part of their training and the scope of the arrangement, workers can remind people to take medicines and mark when the medicine has not been taken, and the buildup of untouched Webster pack days is what indicates a clinical problem.

Attendance. The next appointment is where deterioration is picked up professionally, and it's transport and companion that is often the only distinction between attended and missed.

Turning Presence Into Surveillance

The more a support worker is briefed, the more value they are to the client. The "help with showers and meals" briefing conveys tasks to a worker. The briefing that says this patient is recovering from X, and if you see these things, call this number today, gives you tasks and an early warning system. Nurses are the logical writers of that briefing and it takes only a few minutes: two or three changes that are important to this patient, in layman's terms, with a named contact and a timeframe for response. So long as the reporting line is present, the observation is theirs and the judgement remains clinical.

How This Plays Out In Practice

Imagine that a woman in her seventies is discharged following a cardiac admission, lives alone and was historically readmitted twice in one month of discharge. This time, morning support has been arranged before she leaves the ward: meals, prompting to take the medication and a briefing note by the discharge nurse outlining the changes which need to be reported.

On day 9, the worker calls the number on the note: on the walk to the letterbox the ankles are more swollen than yesterday, and she is breathless. Her GP reviews her that afternoon, makes adjustments to her treatment and the admission process that was building does not go through. The clinical response was all standard. The only thing that was different was that there was someone there on day nine, and they knew what was important.

Next Steps

On your next discharge with a readmission history, write the 10 minute briefing note and ensure that the support person in the home has it. One sheet, three warnings, one number.