Predicting Risk Factors for 30-Day Readmissions Following Discharge From Post-Acute Care

Nina M Flanagan1, Victoria M Rizzo, Gary D James

  • 1Nina M. Flanagan, PhD, GNP, is Assistant Professor, Decker School of Nursing, Binghamton University. Her research focus is on the role of nursing in the management of older adults with cognitive impairment and medical comorbidities. Victoria M. Rizzo, PhD, LCSW-R, is Department Chair and Associate Professor, Department of Social Work, Binghamton University. Her research examines the impact of interprofessional interventions including social workers on older adults coping with chronic illnesses and the implications of health care policy and financing on the provision of these services to older adults. Gary D. James, is Director of the Biomedical Anthropology Program, Director of the Institute for Primary and Preventative Health Care, and Professor of Anthropology, Nursing, and Biomedical Engineering at Binghamton University. He is a fellow of the Society of Behavioral Medicine and AAAS and a member of the Harvey Society. Adele Spegman, PhD, RN, is Director of Nursing Research for the Geisinger Health System in Pennsylvania. Her current studies focus on pain management and nurses' work environment. Dr. Spegman holds degrees from Oregon Health and Science University, University of Minnesota, and Niagara University. Najla A. Barnawi, MS, RN, is PhD candidate at Decker School of Nursing, Binghamton University. She started her career as a clinical instructor in a private diploma nursing institution for one full year. In 2003, she worked as Teaching Assistant at King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS) mainly in maternity and community nursing care.

Summary

Skilled nursing facility residents with congestive heart failure or at very high risk on the Braden Scale face significantly higher 30-day hospital readmission rates. Improving care coordination and communication is key to reducing these readmissions.

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