I'm a nurse whose sole mission is to prevent readmissions. Here is what a day in the life of a Readmission Prevention Nurse looks like.

I identify patients who are at high risk for readmission based on condition, previous hospitalizations or emergency department visits, and any social determinants of health. I then connect with the patient, meeting them in the hospital to establish a relationship. I ascertain who assists the patient in the home and what resources they have or may need. I encourage the patient to involve a caregiver or family member.

I then enroll the patient in a 30-day readmission prevention program. I visit them in the hospital and attend patient-care rounds. I collaborate with the primary nurse, inpatient case manager, and hospitalist to facilitate an appropriate discharge plan. I use Motivational Interviewing to find out what the patient's goals are. (My goals for the patient and their goals need to coincide.) We discuss and I suggest referrals, and evaluate the need and eligibility for palliative care consults or hospice care. (Not all patients are ready for these conversations.)

I call the patient 48 hours after discharge from the hospital to conduct medication reconciliation, assure that physician appointments have been scheduled within 7 days of discharge, and verify that the home care agency has admitted the patient. I review the "Call me!" flyer that encourages patients to call their physicians if symptoms put them into the "yellow zone." This is an action plan that helps the patient know when they are on track and when they need to alert their clinician about a decline in their health. I call and/or visit the patient at intervals that meet the patient's needs. I continue to use Motivational Interviewing techniques and solicit teach-backs to assure the patient is competent and confident in managing the posthospitalization course. I communicate with the home care nurse if the patient has home care services and secure a handoff if the patient is to be discharged from home care within 30 days of leaving the hospital. I also attend discharge planning meetings at the facility to assure a safe discharge. Finally, I write a readmission prevention plan in the patient's chart using the BOOST tool as a guide and provide information that I have gathered from the patient to the emergency department clinician to assist in developing a plan of care.

These are all activities of a Readmission Prevention Nurse. What this description fails to capture is the relationship-the relationship between the patient and me. It is about caring and encouraging. It is about honoring the patient and taking each patient from where they are at. Sometimes it takes place at the beginning of a serious decline and I am welcomed into the start of the patient's path. Sometimes it takes place at the end of a long journey and I am able to support the patient during final days and weeks. Most importantly, I've learned when to listen and not speak, to understand the patient's goals, not mine, and to ask the patient for input. I have learned positive feedback gives patients confidence and reinforces that I'm supporting them. Sadly, not all patients who want to go home get to go home. A patient in short-term rehab had to agree to long-term care because she understood that "If you can't do it here - you can't do it at home."

In the end-it is about helping the patient remain out of the hospital. We often say-Every readmitted patient represents a patient who is suffering. We want to prevent that suffering.