Improving Transition of Care for Veterans after Total Joint Replacement

BACKGROUND: Patients transitioning from hospital to home are at risk for readmission to the hospital. Readmissions are costly and occur too often. Standardized discharge education processes have shown to decrease readmissions. PURPOSE: The purpose of this quality improvement project was to utilize evidence-based practice changes to decrease 30-day all-cause readmissions after total joint replacement. METHODS: Review of literature revealed that improved discharge education can decrease unnecessary readmissions after discharge. A quality improvement project was developed including standardized total joint replacement discharge education, teach-back education methodology, and improved postdischarge telephone follow-up. The quality improvement project was initiated and outcomes were evaluated. OUTCOMES: Improving coordination of the discharge process, enhanced education for patients/caregivers, and postdischarge follow-up decreased total joint replacement readmissions.