D117 Care Plan for Transition- Phase

Overview of the CMS Hospital Readmissions Reduction Program

In 2012, the Centers for Medicare & Medicaid Services (CMS) launched the Hospital Readmissions Reduction Program (HRRP) as part of a federal mandate to enhance patient outcomes by improving communication, discharge planning, and coordination of care. This value-based purchasing program links hospital reimbursements directly to their performance in reducing preventable readmissions within 30 days post-discharge (Centers for Medicare & Medicaid Services [CMS], 2023). The primary objective of HRRP is to encourage hospitals to adopt evidence-based transitional care practices that actively involve patients and their caregivers throughout the discharge process, thereby lowering avoidable readmissions.

CMS evaluates hospital performance in six clinical areas under HRRP: acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA). Hospitals exceeding expected readmission rates in these categories may face financial penalties up to 3% of Medicare reimbursements. Though seemingly modest, these penalties exert considerable pressure on hospitals to investigate the causes of readmissions and improve discharge procedures.

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Why is Transitional Care Planning Crucial in Reducing Readmissions?

Unplanned hospital readmissions often stem from complex and multifactorial causes that extend beyond the natural progression of illness. Systemic factors such as ineffective communication between healthcare providers, medication mismanagement, inadequate follow-up care, and insufficient patient education are frequently responsible. Research by Feigenbaum et al. (2012) highlights missed opportunities in transitional care planning—including medication management, care coordination, and follow-up logistics—as significant contributors to 30-day readmissions.

Hospitals are encouraged to implement structured transitional care plans that can effectively reduce preventable readmissions. For example, elective primary total hip arthroplasty (THA), which is included in HRRP’s focus areas, demands standardized care plans regardless of the patient’s discharge location, whether home or a skilled nursing facility. Since THA complications are often predictable, proactive care coordination is essential to minimize risks.

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What are the Common Clinical Risks and Causes of Readmission after Total Hip Arthroplasty?

Patients undergoing total hip arthroplasty face several potential postoperative complications that may necessitate unplanned readmissions. According to Kurtz et al. (2018), the most frequent causes include surgical site infections, atrial fibrillation, pulmonary embolism, septicemia, and pneumonia. These complications underscore the need for comprehensive patient education, vigilant monitoring, and timely follow-up during the transition from hospital to home care.

The following table outlines the common complications after THA, associated risk factors, and preventive strategies:

Potential Complication	Risk Factors	Preventive Strategies
Surgical site infection	Obesity, diabetes, poor wound care	Antibiotic adherence, wound care education
Deep vein thrombosis / pulmonary embolism	Immobility, obesity	Anticoagulation therapy, early mobilization
Pneumonia	Reduced mobility, shallow breathing	Incentive spirometry, ambulation
Joint dislocation or injury	Unsafe movement, unsafe home environment	Hip precautions, home safety modifications
Medication-related adverse events	Polypharmacy, allergies	Medication reconciliation, patient education

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Patient Case Scenario: Susan

Susan is a 68-year-old woman with advanced osteoarthritis scheduled for elective total hip arthroplasty. She has multiple comorbidities, including obesity (BMI 36.9 kg/m²) and depression. These factors increase her risk of postoperative complications and hospital readmission, making meticulous discharge planning vital.

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What is the Role of the APRN in Preventing 30-Day Readmission?

The Advanced Registered Nurse Practitioner (APRN) plays a crucial role in coordinating Susan’s discharge and minimizing her readmission risk. One key responsibility involves preventing infections by ensuring Susan completes her prescribed antibiotic course post-surgery. Given Susan’s penicillin allergy, clindamycin is prescribed as an alternative, though the APRN must educate her about the risk of Clostridioides difficile infection and symptoms such as persistent or bloody diarrhea.

The APRN also provides detailed instructions for surgical site care, emphasizing the importance of reporting early signs of infection—redness, warmth, swelling, pain, or drainage—to the orthopedic team. Maintaining clear communication with the surgical providers during this critical transition supports continuity of care.

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How Should Medication Management and Anticoagulation Be Handled?

Effective medication management is vital to prevent adverse events. Susan should be discharged with a comprehensive, clearly explained medication list shared with her primary care provider. This list includes drug names, dosages, administration schedules, and therapeutic purposes.

To reduce the risk of thromboembolic events, Susan’s prophylactic regimen includes daily low-dose aspirin, injectable enoxaparin until the prescribed course ends, and encouragement of regular ambulation. Pain management should utilize a multimodal approach, combining NSAIDs, opioids as needed, and scheduled acetaminophen to promote mobility and reduce immobility-related complications.

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What Nutritional and Weight Management Strategies Are Recommended?

Obesity complicates Susan’s recovery and long-term joint health. Initially, a soft, bland diet is recommended, advancing as tolerated. Adequate protein intake is essential to support wound healing and tissue repair. Once stabilized, Susan’s primary care provider should work with her on sustainable weight management to decrease joint load and prevent further musculoskeletal deterioration.

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How Can Mobility, Physical Therapy, and Home Safety Be Optimized?

Strict adherence to hip precautions taught during inpatient physical therapy is necessary to prevent joint injury. Susan and her family should receive education on safe movements and necessary home modifications to minimize fall risks. Recommended home safety adjustments include removing clutter, installing raised toilet seats, using shower chairs, and employing pillows or bed risers.

Durable medical equipment such as walkers and continuous passive motion (CPM) devices should be provided before discharge. Scheduling outpatient physical therapy visits in advance and arranging reliable transportation are also critical to ensure adherence to rehabilitation plans.

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How Can Pulmonary Complications Be Prevented?

Pulmonary complications like atelectasis and pneumonia are common preventable causes of readmission after THA. Susan should be encouraged to use incentive spirometry, practice deep breathing and coughing exercises, maintain adequate hydration, and ambulate regularly. Clear, understandable written instructions reinforce adherence to these pulmonary care strategies.

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How Does Multidisciplinary Discharge Planning and Social Support Affect Readmission Risk?

Before discharge, Susan should undergo evaluation by a multidisciplinary team including physical therapy, occupational therapy, and social work to confirm that her home environment is safe and supportive. Addressing social determinants—such as access to transportation, medication refills, grocery shopping, and family support—is essential. Insufficient logistical and social support significantly raises the risk of readmission.

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How Was the Care Plan Reviewed and Improved?

This transitional care plan was reviewed by MaryEllen Kopp, APRN, a postsurgical cardiac advanced practice provider. She emphasized the need for multidisciplinary discharge clearance, close monitoring for Clostridioides difficile infection, and clear patient education on infection symptoms. These insights enhanced the clinical applicability and quality of the plan, informing ongoing and future care strategies.

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References

Centers for Medicare & Medicaid Services. (2023). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Feigenbaum, P., Neuwirth, E., Trowbridge, L., Teplitsky, S., Barnes, C., Fireman, E., Dorman, J., & Bellows, J. (2012). Factors contributing to all-cause 30-day readmissions: A structured case series across 18 hospitals. Medical Care, 50(7), 599–605. https://journals.lww.com/lwwmedicalcare/Abstract/2012/07000/Factors_Contributing_to_All_cause_30_day.7.aspx

D117 Care Plan for Transition- Phase

Kurtz, S., Lau, E., Ong, K., Adler, E., Kolisek, F., & Manley, M. (2016). Which hospital and clinical factors drive 30- and 90-day readmission after total knee arthroplasty? The Journal of Arthroplasty, 31(10), 2099–2107. https://www.sciencedirect.com/science/article/pii/S0883540316300043

Phruetthiphat, O., Otero, J. E., Zampogna, B., Vasta, S., Gao, Y., & Callaghan, J. J. (2020). Predictors for readmission following primary total hip and total knee arthroplasty. Journal of Orthopaedic Surgery, 28(3). https://journals.sagepub.com/doi/10.1177/2309499020959160