Community & Public Health Reducing Hospital Readmissions Among High-Risk Patient Populations. Select a diagnosis among high-risk patient populations that are commonly readmitted to the hospital. Examines the rationale for readmissions among this population and provide evidence-based interventions for reducing hospital readmissions in this population.
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One diagnosis among high-risk patient populations that is commonly associated with hospital readmissions is heart failure (HF). Heart failure is a chronic condition that affects the ability of the heart to pump blood effectively, and patients with HF are at high risk of hospital readmission due to exacerbations of their condition.
The rationale for readmissions among this population is multi-factorial and can include lack of symptom recognition and management, poor medication adherence, lack of follow-up care, and social determinants of health such as poverty, limited access to transportation and lack of social support.
There are several evidence-based interventions that have been shown to reduce hospital readmissions among patients with HF. These include:
Disease management programs: These programs provide education and support to patients with HF on how to manage their symptoms, recognize signs of deterioration, and access appropriate care.
Telemonitoring: This technology allows for remote monitoring of patients’ vital signs and symptoms and can help identify deterioration early and intervene before hospitalization is needed.
Medication management: Ensuring that patients receive appropriate medications, have proper dosing, and are educated on proper use of medication can reduce readmission.
Transitional care: Coordinating care between hospital and home can help to ensure that patients have appropriate follow-up care and support after discharge.
Social determinant of health interventions: Addressing social determinants of health such as poverty, lack of transportation, and limited social support can improve access to care and reduce readmissions.
Patient-centered care approach: involving patients in their care plan and providing them with information can help ensure they understand their condition and how to manage it better.
Multidisciplinary team approach: involving different healthcare professionals in the patient’s care can help identify the barriers to discharge and work towards reducing readmissions.
Care coordination: having a designated care coordinator can help ensure continuity of care and reduce readmissions.
It is important to note that reducing hospital readmissions is a complex and multifaceted task, and a combination of interventions that address the specific needs of the patient population is likely to be most effective.

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