Nowadays the sphere of healthcare is facing one of the most debated issues – how to develop a way for the patient’s transition after being discharged from the hospital efficient and cost-effective (Aguirre, 2012, p. 5). The proposed plan is targeted at finding ways of reduction of instances of readmissions to the hospitals as well at answering the question of whether a transitional care management appointment can be an answer to minimizing instances of hospital readmission in patients with congestive heart failure.
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Change Model Overview
The solution model used in the proposal is the Johns Hopkins Nursing Evidence-Based Practice that is one of the most effective approaches towards decision-making about clinical issues. It is widely used by my nursing practitioners for its simple tools that guide both group and individual levels. The evidence-based model was created to fit the requirements of practicing nurses that implement a three-step approach which includes the practice question, evidence, and translation (Johns Hopkins Nursing Evidence-Based Practice Model, n.d., para. 1).
The components of the evidence-based practice are the following: P – problem, patient, population, I – intervention, C – comparison with already existing interventions, and O – outcomes of the intervention.
Interprofessional Team Recruitment
Since the issue of CHF patients, readmission is pervasive it requires skilled staff that is included in the resolving of the issue. Physicians and nursing practitioners are the primary stakeholders of the proposal since they are the ones that can evaluate the state of the patient during his or her TCM appointment. The second group are patients themselves; when properly informed about the complications CHF can cause during the transition period, patients will be able to identify whether there is something wrong and come to the hospital for additional checking; thus, the readmission will be done only in critical instances. Lastly, public and non-profit organizations that operate in the sphere of nursing practice will become drivers to raising awareness of the issue of readmission and encourage individuals that suffer from CHF to attend transitional care management appointments to reduce the instances of readmission.
The evidence-based practice question for the proposal is the following: does a transition care management appointment within two weeks of hospital discharge decrease the chance of hospital readmission in the adult congestive heart failure patients. The PICO components of the evidence-based plan include P – congestive heart failure patients that have recently been discharged from the hospital; I – a patient scheduling a transitional care management appointment within two weeks of the initial discharge from the hospital; C – a patient that does not schedule a follow-up appointment; and lastly, O – the patient is not readmitted to the hospital as the result of the TCM appointment, the number of readmission instance decreases.
The question outlined above has appeared based on major issues that exist in the sphere of nursing practice. The issue of hospital readmission has been under an increased focus over the last decade. Furthermore, the hospitals that deal with relatively higher levels of readmissions face the reduction in funding reimbursements. The problem of readmission is also tightly linked to congestive heart failure as a medical issue that has been recognized as the main cause of 20-30 day readmissions to hospitals. According to the Centers for Disease Control, congestive heart failure is a problem that affects up to five million people in the United States of America alone and requires more than thirty-two billion dollars in funding annually. Adults are predominantly exposed to the issue since the instances of heart failure become more frequent with age (Franks, 2015, p. 7).
According to the Medicare Payment and Advisory Committee, heart failure is the primary cause of patients being readmitted to hospitals, with up to thirty percent of initially admitted patients being readmitted within the twenty-day timeframe (Franks, 2015, p. 8).
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Team Members Responsibilities
Any health care proposal will work in the case with all team members working together towards a set goal. Nursing staff should develop a pattern of CHF patients care during the transition appointment to eliminate the instances of readmission; the patients should not overlook primary symptoms and get help as soon as possible; public organizations should be a facilitator of conversation between hospitals and patients, ensuring that the public is well-informed on the issue of readmission and increased cases of CHF.
According to the quantitative research conducted by Naylor (2011), the health care system requires $500 million to cover the expenses caused by the hospital readmissions (p. 11). A recent qualitative study by the Robert Wood Johnson Foundation (2013) was targeted at evaluating the effectiveness of transitional care for CHF patients by involving the control and the transitional care group (p. 3). Karen Shields (2012) targeted the qualitative research at answering the question of whether adults who are admitted with heart failure to an acute care facility who are guided by an APN after discharge have lower readmission rates (p. 4). Franks (2015) quantitative and qualitative research was focused on reducing the instances of hospital readmissions in the elderly (p. 5).
Summarizing the collected evidence, hospital readmission of CHF patients requires major increases in the medical system funding (Naylor, 2011, p. 14). The Robert Wood Johnson Foundation’s (2013) research has resulted in designing a theoretical framework that guided the follow-up care of patients that come for a transitional appointment (p. 39). According to Shields (2012), patients admitted to an acute care facility after discharge exhibit lower rates of admission (p. 21). Franks (2015) concluded that the reduction of readmissions in the elderly is tightly linked to control and transitional care (p. 32).
Based on the evidence, the primary recommendation is making sure that the discharged CHF patients schedule for the follow-up appointment to reduce the instances of readmissions.
The project plan includes the following three steps: scheduling a required follow-up appointment for all discharged patients within two weeks; if the patient notices any symptoms, contact a health institution immediately; providing support for CHF patients that did get readmitted to the hospital.
The primary outcome of the plan is the reduction of readmission instances in CHF patients, backed up by raising awareness of the issue. The results will be provided in the form of a complete report.
On a larger scale, the plan will be implemented in cooperation with health organizations and institutions that want to reduce the instances of hospital readmission. By raising awareness and promoting the main steps of plan implementation, the project has the potential to make a difference.
Within the health organization, the findings will be communicated via reports and practical advice while external communication will be facilitated by public organizations and media resources.
A transition care management appointment within two weeks of hospital discharge can decrease the chance of hospital readmission in the adult congestive heart failure patients. Based on the reviewed evidence, CHF is one of the main contributors to hospital readmission and requires additional funding. The solution action plan is linked to raising awareness of the problem, encouraging patients to schedule a follow-up appointment and make sure that nursing practitioners take possible risks into account.
Aguirre, F. (2012). Strategies for Reducing Hospital Readmissions through Better Transitions of Care. Readmission News, 11(1), 5-11.
Franks, S. (2015). Transitional Care to Reduce 30-day Heart Failure Readmissions Among the Long-Term Care Elderly Population. Web.
Johns Hopkins Nursing Evidence-Based Practice Model. (n.d.). Web.
Naylor, M. (2011). The Transitional Care Model for Older Adults. Web.
Robert Wood Johnson Foundation. (2013). The Revolving door: A report of U.S. Hospital Readmissions. Web.
Shields, K. (2012). Transitional Care-APN Guided Care Coordination. Web.
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