Identifying patients with high risk of readmission from the patient navigators’ perspectives: a descriptive qualitative study

Background: Unplanned readmission incurs additional cost to patients and contributes to the rising healthcare cost of our nation. Although numerous studies have investigated the predicting factors that contribute to hospital readmission, the majority of the studies focused on clinical and patient-related factors, and were not from the perspectives of clinicians such as patient navigators (PNs). Aim: To understand factors that predict patients’ readmission risks from the PNs’ perspectives. Method: Using purposive sampling, PNs with a minimum of 10 years of clinical experience in the adult acute-care setting participated in the focus group interviews. Thematic analysis was adopted. Findings: All 10 PNs agreed that the readmission risk assessment tool was useful as a guide to assess patients’ risk of readmission; however, they also mentioned the use of clinical judgement and experience while assessing their patients. Three themes emerged from this study: (1) looking beyond medical-related issues; (2) social and community support; (3) functional status of patients. Conclusion: Predicting patients’ risk of readmission is closely tied to the patients’ current medical conditions and caregiving needs. Ensuring individualised readmission risk assessment and identifying social issues early are key in ensuring a holistic discharge planning