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Aims and objectives. To investigate the elderly patient’s perspective about the reasons for discharge to home being unsuccessful, resulting in rehospitalization. Background. Elderly patients have a high rate of readmission to the hospital within 30 days of discharge. Starting in October of 2013, hospitals having a high rate of readmission of patients with heart failure (HF), myocardial infarction (MI), and pneumonia (PNA) will face financial penalties. Evidence indicated that by utilizing risk prediction tools and incorporating transition interventions the risk of a hospital readmission may be reduced. Design. A qualitative, descriptive design was used. Methods. In 2013, a student investigator interviewed elderly patients over the age of 65 who were readmitted to the hospital with the diagnosis of HF, MI, PNA or chronic obstructive pulmonary disease (COPD) within 30 days of discharge. A total of six (N=6) patients and/or surrogates participated in the interviews. Data were collected using semistructured interviews and subjected to thematic content analysis. Results. Three major themes emerged: discharge readiness, communication, and education. Implications for the advanced practice registered nurse (APRN). Practicing in an APRN role provides the opportunity for the nurse to facilitate the appropriate transitional care of elderly patients placing them at less risk for hospital readmission within 30 days.

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