Tiffany Clack

Tiffany Clack

Baylor Scott & White Health Transitional Care, USA

Title: 5 factors that impact hospital readmissions in the aging population & what we are doing about it


Tiffany Clack is a passionate person pursing her childhood dream career in nursing. She’s dedicated to providing care to the older adult population. She obtained a Master
of Science in Nursing degree from University of Texas for Adult & Gerontological Nurse Practitioner and board certified by American Nurse Credentialing Center


The interdisciplinary Transitional Care team at Baylor Scott & White in Dallas, Texas is focused on readmission reduction of patients aged 65 and beyond with a primary inpatient diagnosis of Heart Failure, COPD or Pneumonia. All patients are followed by the registered nurse, licensed masters social worker (LMSW), pharmacist, medical assistant, and advanced practice registered nurse (APRN) for 30 days post hospitalization. Through our remote tele monitoring system, daily health checks are completed and reviewed by the team. High risk patients also receive APRN home visits. Several categories were identified detailing the reoccurring reasons for hospital readmissions. Reasons included patient and system level factors, sociodemographics, as well as communication challenges. Evaluating patients for the development of post-acute care risks was conducted via APRN inpatient geriatric assessment. Second, a post hospitalization telephonic assessment was completed by the team’s LMSW. From October 2015 to May 2016, 162 readmissions were reviewed. The most prevalent reasons contributing to the readmission were:

  1. Patient declined services (31%)
  2. Insufficient patient and caregiver education (31%)
  3. Unpredicted medical emergency (10%)
  4. Medication mismanagement (7%)
  5. Provider initiated readmission (7%)

Our team developed an action plan that enhances communication with acute & post-acute care providers. This created a more cohesive partnership to combat readmission. In addition to reinforcing the importance of patient adherence, our team educated patients in lifestyle behavior changes. We found this to be relevant to their healthcare treatment plan which resulted in improved quality of life.