Hospital Readmissions and Care Coordination

Patient outcomes are a critical focus of most quality improvement initiatives in the United States healthcare sector. Enhancing patient outcomes requires a comprehensive effort of policymakers and care providers, including nurses.

Hospital readmission is among the key patient outcomes to be targeted in the United States because it has a direct influence on healthcare costs and population health. Ensuring adequate care coordination can assist in decreasing the rate of hospital readmissions for all patient groups by linking the efforts of acute and primary care providers. The present paper will discuss the issues of hospital readmissions and care coordination and relate them to the American Nurses Association Code of Ethics.

Background of the Problem

Hospital readmissions are an important problem in the U.S. since they influence other patient outcomes and double the costs of treating a patient. The risk of readmission depends on the patient’s illness and can be higher for certain conditions, including heart failure and stroke. For example, according to Bambhroliya et al. (2018), the 30-day readmission rate for patients with intracerebral hemorrhage and acute ischemic stroke were 13.7% and 12.4%, respectively. Another study by Zohrabian, Kapp, and Simoes (2018) found that between 15.5 and 30.4 percent of patients with heart failure were readmitted to a hospital within 30 days.

High patient readmission rates have a detrimental effect on other patient outcomes since the persistence of a health issue can lead to complications. Moreover, readmissions contribute to the country’s healthcare expenses, especially if the cost of treating a readmitted patient is higher than the cost of initial care (Bambhroliya et al., 2018). Thus, the problem is of critical importance in the U.S. healthcare sector and should be addressed by a comprehensive effort, which would include the improvement of care coordination.

Care coordination plays a pivotal role in reducing hospital readmissions. Yoder (2017) notes that adequate care coordination involves discharge planning and providing patient education necessary to increase their adherence to the plan of care. Additionally, care coordination can help to establish effective communication between primary and acute care providers, as well as community health workers. This, in turn, could contribute to decreasing readmission rates by ensuring follow-up and monitoring (Yoder, 2017). There is also substantial research evidence portraying the connection between care coordination and hospital readmissions.

For example, Hollingsworth Forbes (2014) reports that nurse-led care coordination initiatives helped to reduce readmission rates of patients by 8.3%. The same study also shows a decrease in the length of hospital stay, thus leading to significant cost savings (Hollingsworth Forbes, 2014). Based on this information, it is evident that increasing care coordination should be an integral part of quality improvement initiatives that seek to reduce readmission rates and enhance other patient outcomes.

Care Coordination and the ANA Code of Ethics

Improving care coordination would also reflect the adherence of care providers to the ANA Code of Ethics, which is the primary document describing the desired conduct and values of nurses. The Code, revised in 2015, includes nine provisions concerning the key issues and subjects in healthcare and patient care, such as patient privacy, advocacy, and health disparities (Winland-Brown, Lachman, & Swanson, 2015). Enhancing care coordination would help to promote a meaningful change in nursing practice that would reflect the values and principles incorporated in the Code. In particular, three main provisions apply to the issue of care coordination in U.S. healthcare.

First of all, the second provision of the Code states that nurses should be committed to their patients and prioritize the patients’ interests above those of other clinicians, family members, and other parties (Winland-Brown et al., 2015). Improved care coordination is in patients’ best interests since it would reduce the need for additional hospital stays and prevent complications. Moreover, the activities involved in care coordination, such as patient education, assist in raising patients’ capacity for self-care and their health literacy. This, in turn, reduces the risk of serious illness and helps patients exercise their autonomy in healthcare.

Secondly, Provision 4 of the Code states that “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care” (Winland-Brown et al., 2015, p. 270).

There are two components in this provision that relate to the issue of care coordination in nursing. On the one hand, discharge planning is part of nurses’ decision-making that allows fulfilling their responsibilities to the patient. On the other hand, care coordination assists in promoting health and providing optimal care both during and after hospitalization. Therefore, improving care coordination is an example of action consistent with nurses’ obligations.

Thirdly, the eighth provision of the Code sets forward the requirement for nurses to collaborate with other health professionals and the public (Lachman, Swanson, & Winland-Brown, 2015). While interdisciplinary collaboration is essential to improving patient outcomes, the Code supposes that it should also aim to reduce health disparities (Lachman et al., 2015). The question of health disparities is particularly relevant in the context of care coordination due to its impact on hospital readmissions. According to a study by Basu, Hanchate, and Bierman (2018), there are certain racial and ethnic disparities in readmission rates.

The findings of the study imply that the variations in readmission rates between insured white populations and other groups are related to the lack of insurance coverage and decreased quality of care provided to black and Hispanic populations (Basu et al., 2018). Ensuring collaboration with community health providers and engaging them in care coordination efforts would help to reduce these disparities, thus reflecting the values promoted by the Code.

Advocating for Improvements

There are two main options for nurses to advocate for improvements in care coordination. First of all, nurses can find other local care providers with similar goals and concerns through professional organizations (Warner, 2017).

As a group, they could create a change plan to enhance care coordination in the area and present it to their institutions’ leaders or local legislators. Secondly, nurses can also engage in advocacy by contacting their representatives and other decision-makers directly to draw their attention to the issue (Warner, 2017). While an individual nurse might have less power to facilitate change than an organized group, they could still provide information and assistance to help legislators in planning and implementing a solution to the problem.


Overall, high readmission rates harm patient health and increase the overall healthcare expenditures in the country. Care coordination improvements could help to address this issue by enhancing discharge planning and fostering communication between care providers. Developments in the area of care coordination would reflect provisions 2, 4, and 8 of the ANA Code of Ethics by having a positive influence on patient outcomes and population health. To advocate for enhanced care coordination, nurses should write to legislators or their institutions’ leaders collectively, although individual advocacy could also be useful.


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Basu, J., Hanchate, A., & Bierman, A. (2018). Racial/ethnic disparities in readmissions in US hospitals: The role of insurance coverage. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 55(1), 1-12.

Hollingsworth Forbes, T. H. III. (2014). Making the case for the nurse as the leader of care coordination. Nursing Forum, 49(3), 167-170.

Lachman, V. D., Swanson, E. O. C., & Winland-Brown, J. (2015). The new ‘Code of Ethics for Nurses with Interpretative Statements’: Practical clinical application, Part II. MedSurg Nursing, 24(5), 363-368.

Warner, S. L. (2017). Getting political about patient advocacy. Nursing 2017, 47(11), 47-49.

Winland-Brown, J., Lachman, V. D., & Swanson, E. O. C. (2015). The new ‘Code of Ethics for Nurses with Interpretative Statements’: Practical clinical application, Part I. MedSurg Nursing, 24(4), 268-272.

Yoder, L. (2017). Care coordination and transition management: Critical roles for medical-surgical nurses. MedSurg Nursing, 26(4), 225-227.

Zohrabian, A., Kapp, J. M., & Simoes, E. J. (2018). The economic case for US hospitals to revise their approach to heart failure readmission reduction. Annals of Translational Medicine, 6(15), 298-304.