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Discharge Plans and Readmission as Practice Issue

Practice Issue

What practice issue has been identified related to the chosen topic?

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Standard hospital-discharge plans are often insufficient in the information they provide to the patients with chronic illnesses. Aspects such as emotional well-being of the patient, the use or creation of a support network and even daily activities may need additional attention that can only be provided by caseworker-assigned plans.

What is the scope of the practice issue?

The scope of the practice issue encompasses patients between the ages of 40-60 with HF that were readmitted to a hospital within 30 days of discharge. The study is set to be conducted over a six-month period.

What is the practice area?


How was the practice issue identified?

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Unsatisfactory patient outcomes

What is the rationale for the checked selection?

The primary identifier for this practice issue lies in the unsatisfactory patient outcomes shown by the frequent readmissions to the hospital. People with chronic diseases have shown to be more commonly readmitted within 30 days of hospital discharge. It is likely that the information given to them upon discharge does not align with their needs. The majority of the information is focused on the disease itself while omitting crucial information about living with the chronic condition on a day-to-day basis. This omission may be a primary factor in the frequent readmission of the patients with chronic diseases.

What evidence must be gathered?

  • Literature search
  • Patient Preferences

What is the rationale for the checked selections?

To better understand the differences between standard and personalized discharge plans it is important to review all cases that would fit the requirements of the study. It would also be beneficial to examine the preferences of the patients because it would demonstrate which discharge plans are more effective at conveying important information.

Evidence Summary

The practice problem with reference to the identified population, setting and magnitude of the problem in measurable terms

Recent monitoring shows that a disproportionate number of patients with chronic diseases have to be readmitted to the hospital within 30 days of discharge. Approximately more than double the number of patients that are readmitted have a chronic disease. The issue is likely connected to the standard discharge plans that are focused on the aspects of life-related to the disease but often omit any information about daily life, including emotional concerns that the patient with a chronic condition needs to be aware of. Patients between the ages of 40-60 with HF are readmitted especially often, which makes them the primary population for the intervention.

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Discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness

The objectives of the article

The objective of the article is to determine the efficacy of individualized caseworker-assigned discharge plans by comparing them to standard non-caseworker-assigned discharge plans, in reducing the instances of readmission for patients with acute respiratory exacerbations. The article is specifically focused on cases involving children with chronic lung diseases but suggests that this approach can be applied to patients of all ages afflicted with other chronic conditions.

A statement of the questions being addressed in the article

The selected systematic review addresses a number of relevant questions. The review touches upon the possible reasons for the increased readmissions among patients with chronic diseases. It provides a possible intervention to the issue. The efficacy of the proposed intervention is also analyzed through a literature review of discharge plans of different types.

The interventions the authors suggest to improve patient outcomes

The authors of the article propose the use of individual caseworker-assigned discharge plans for patients with chronic conditions. They also describe the activities that the caseworkers could be performing to improve patient outcomes. They include the creation of the discharge plan with consultations from relevant health services, collaboration with agencies focused on home health, and education of the patient combined with emotional support. However, the article states that additional activities may be included (Hall, Chang, & O’Grady, 2016).

The main findings by the authors of the systematic review including the strength of evidence for each main outcome

The provided article is a protocol for the upcoming review and does not feature the final outcomes of the study. However, it provides the outline for the outcomes that would be measured in the final paper. They include the rate and frequency of readmissions, rate of unscheduled healthcare visits, quality of life post-discharge, cost-effectiveness, duration of stay after readmissions, adherence to the plans, and mortality rate post-discharge. The strength of evidence would be determined based on the gathered information during the study. The same outcomes may be measured in the subsequent project proposal.

Evidence-based solutions to be considered for the project

The primary evidence-based solution for my project would be creation of personalized and detailed discharge education and plans for patients with the goal of providing at-home care and self-management.

Secondary, involvement of caseworkers in the development of discharge plans may be beneficial to the patients with chronic conditions. Additional studies suggest that it may be especially effective for older patients (Rodakowski et al., 2017).

Limitations to the studies performed that impact the ability to utilize the research in the project

The main limitation of the studies is the possible variation in the needs of patients with different chronic conditions. It is possible that people with respiratory conditions may have a different response to the personalized discharge plans than people with other conditions. However, additional research may reveal if this concern is valid or not.


Hall, K. K., Chang, A. B., & O’Grady, K. F. (2016). Discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness. Cochrane Database of Systematic Reviews, (8), 1–9. Web.

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Rodakowski, J., Rocco, P. B., Ortiz, M., Folb, B., Schulz, R., Morton, S. C., … James, A. E. (2017). Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis. Journal of the American Geriatrics Society, 65(8), 1748–1755.

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