Self-management of chronic disease and hospital readmission: a care transition strategy


Michelle D Kelly
1801 East Cotati Ave,
Rohnert Park, CA 94928
Telephone: 707 498 7773


kelly md (2011) Journal of Nursing and Healthcare of Chronic Illness 3, 4–11
Self-management of chronic disease and hospital readmission: a care transition strategy

Aims and objectives.  To identify current trends in readmissions and practices for preventing readmissions in client populations with chronic disease. The objectives are to review evidence and ascertain if best practice guidelines to prevent readmissions exist. An emphasis was placed on the identification of low resource and easy to implement models for the prevention of readmissions.

Background.  Chronic disease is increasing in prevalence, and quality improvement is needed as clients transition between a variety of healthcare settings, particularly from hospital to home. People with chronic disease are more likely to need inpatient care, yet studies indicate that readmissions within 30 days of discharge occur. Hospitalisations are considered preventable if linked to unresolved conditions present at the time of discharge and not remunerated by Medicare. In such cases, hospitals bear 100% of the cost of avoidable readmissions.

Method.  A literature review of databases in English, Internet searches of CINAL, Cochrane database of systematic reviews as well as Agency for Healthcare Quality Research guidelines were conducted. The search terms used were; care coordination, self-care, self-care management of chronic disease, readmission, preventing readmission, and care transition(s).

Results.  The association of chronic disease care with the emergence of readmission rates as indicators of quality of care is explored utilising Coleman’s Care Transition Model. This model is suggested as a practical, evidenced-based intervention, which hospitals can implement to reduce avoidable readmissions.

Conclusions.  The review of evidence revealed a lack of high-level research identifying which interventions designed to avoid readmissions were most effective. The available literature provided several recurrent themes concerning effective strategies to prevent readmission. The themes identified were; patient empowerment and carer inclusion, bridging discharge process from hospital to the client’s home, improving self-care capacities and better client understanding of self-administration of medication. Coleman’s model consisting of four pillars coincided with effective strategies prominent in the literature. The concept of care transitions is contemporary and very much evolving. New higher-level evidence is needed as models addressing decreasing readmission are rigorously evaluated.

Relevance to clinical practice.  Putting measures into place known to prevent hospital readmission is essential in the provision of quality of care and to addresses rising healthcare costs. Supporting clients with chronic disease through care transitions has been identified as a means to avoid hospital readmissions. Coleman’s model provides a low resource template to build self-care into a client’s discharge process after hospitalisation.