Preventing Unnecessary Hospital Readmissions

¶ … causes for Medicare and Medicaid patients to be readmitted to hospitals within thirty days of a prior discharge. This is a fairly pervasive and major problem and it is one that demands solutions. As part of this capstone, there will be a number of facets and tools used. There will be a problem description that identifies what the problem is and why it is important. There will be a solution description that broadly asserts what is needed to address and resolve the problem identified.

There will be an implementation plan that will lay out how the program will be rolled out to the locations and the people that work therein. There will also be an evaluation plan that will be used to monitor and assess performance so that any deficiencies can be spotted and addressed before they become full-on conflagrations that can sap the performance and outcomes of the project.

There will be plan dissemination plan that will describe precisely how the information about the project, the problem and the solution will be propagated to the people involved including nurses, stakeholders and so forth. Finally, there will be a review of scholarly literature that will clearly show that the problems and solutions in this document are truly based on evidence-based practice and not wishful thinking.

Evidence-based practice, often shortened to EBP, is a cornerstone of nursing and medical practice and should be part of any scholarly endeavor to address problems and improve outcomes or performance. Problem Statement The problem that shall be addressed in this report is the alarming high rate of readmissions that occur when it comes to Medicare and Medicaid patients after they are discharged from a hospital. There are exceptions, of course, but readmissions after such a short time horizon should be the exception rather than the rule.

Thus, it needs to be figured out why so many are readmitted seemingly unnecessarily and what can be done to address the problem. Whether it be quality of care, lack of timely and appropriate feedback from the patient or other things, this would seem to be an entirely preventable problem and one that should absolutely be fixed so as to improve the quality of outcomes and quality of life of the patients involved and the performance levels of the medical institutions in question.

Solution Description Any solution to the problem described involved will involve the lowering of readmission rates for the medical institutions in question. Whether this be longer stays for patients so that they can be monitored more completely, asking patients better questions, imploring patients to be completely open and honest, educating patients on how to avoid further or new complications or others, there is probably not a single variable or issue that is causing the problem.

Regardless, whatever problem or problems that exist need to be fully identified in terms of what is going on and why it happening. Once that is done, solutions can and should be figured out, designed and then implemented. Incorporating Theory Ronald Lippitt's organizational change theory follows the exact steps as the nursing process: assessment, planning, implementation, and evaluation to promote and effect change (Mitchell, 2013). This theory supports my proposal for planning, implementing, and evaluating the proposed Case Management-based post-acute follow-up and care coordination for Medicare and Medicaid patients.

Main Components of Theory The main components of Ronald Lippitt's organizational change theory include assessment, planning, implementing, and evaluation (Mitchell, 2013). Each of these components are fluid and will be applied through every phase of the project. Assessment is the process of defining the problem, supporting it with data, and identifying a solution. The planning stage encompasses planning throughout the project as well as ongoing planning to fine tune processes after the solution is implemented (Mitchell, 2013).

Implementation is the process of putting the plan into practice and the steady management of the components (Mitchell, 2013). Evaluation is another component that is fluid throughout the project. The team will evaluate the project's progress throughout each phase, as well as determine how the changes impact the identified problem of 30-day Medicare and Medicaid readmissions. Rationale for Selecting Theory This theory was selected based on the idea that it incorporates all the steps needed to work successfully on the project as well as to implement the proposed change.

I believe that the initial implementation is only the beginning of the long-term solution. As the new post-acute Case Management team begins functioning, it will require the fundamentals of Lippit's change theory to be an ongoing process. The team will continue to assess processes, implement changes as needed, and evaluate the results with the focus of ongoing improvement (Mitchell, 2013). How Theory Supports Proposed Solution Ronald Lippit's change theory supports the proposed solution by providing the foundation for the project itself and the ongoing implementation of the solution.

The steps outlined in Lippitt's change theory closely resemble the nursing process, and this compatibility will lead to consistent application. (Mitchell, 2013). Incorporating Theory into Project Ronald Lippitt's change theory is the foundation of this project and provides the framework for how it will be completed. First the author of this project assessed the problem, developed a proposed solution to address it, and researched peer-reviewed evidence-based literature that supports it. Second will be the planning phase of the project (Mitchell, 2013).

The second step is to define how the proposed change will be developed, communicated to stakeholders and staff, and implemented into practice. Evaluation is conducted during all phases of the project as well as throughout the implementation, including one year after the change has been implemented (Mitchell, 2013). In conclusion, Ronald Lippitt's change theory is an effective tool for implementing new processes as well as overseeing the change proposed.

The proposed post-acute Case Management team to follow-up and coordinate post-acute care for Medicare and Medicaid patients to reduce 30-day hospital readmission rates will involve the same fundamentals that are defined in the change theory. Implementation Plan One of the costliest and common phenomenon in the modern healthcare system is the increased rates of readmission to hospital of Medicare and Medicaid patients within a short period after discharge i.e. usually within the first 30 days.

These readmissions are usually caused by progression of chronic diseases among these patients as well as insufficient post-discharge care. Actually, insufficient post-discharge care is the major factor contributing to these preventable re-hospitalizations. Therefore, reducing the rates of readmissions to hospital of Medicare and Medicaid patients requires developing and implementing a new or enhanced plan for patients' follow-up after discharge. According to the findings of a recent survey, 22% of patients admitted to hospitals are either re-hospitalized or visit an emergency department within the first month after discharge (Harrison et al., 2011, p.27).

This plan focuses on preventing readmission of these patients through post-discharge care based on follow-up. Current Problem Requiring Change As previously mentioned, the healthcare environment is increasingly characterized by high rates of readmission of Medicare and Medicaid patients since they suffer from chronic diseases. These high rates have partly been attributed to progression of the chronic illnesses but largely influenced by inadequate post-discharge care. The post-discharge care is insufficient because of poor communication between the patient and the health care team during and after discharge (Harrison et al., 2011, p.27).

Recent surveys have indicated that approximately 22% of admitted Medicare and Medicaid patients are either re-hospitalized or visit and emergency room within 30 days of discharge if they don't die. The increased readmission has considerable impact on the health and well-being of these patients in addition to increasing health care costs. Therefore, it is increasingly important to develop effective plans for post-discharge care in order to improve patient outcomes and lessen health care costs.

Obtaining Approval & Support The first step towards the implementation of this plan on preventing 30 day readmission on Medicare and Medicaid patients is obtaining required approval and securing support from the organization's leadership and fellow staff. This will involve conducting a meeting with the leadership team in which the rationale and positive effects of the proposed plan will be discussed. These discussions will be carried out in a board meeting, which will review the organization's current environment and practices as well as examine the needs for implementing an evidence-based project.

Similarly, securing support from fellow staff will entail discussing the current best practices in lessening readmission rates and how these practices will be incorporated in the organization. During this process, the roles and responsibilities of the staff in the implementation of the proposed project will be discussed and clarified. Explanation of Proposed Solution The proposed solution for preventing 30 days readmission of Medicare and Medicaid patients is a process or procedure that focuses on post-discharge care through follow-up phone calls after discharge and follow-up appointments with primary care physicians.

Generally, follow-up phone calls by nurses after patient discharge have widely been adopted as a means of enhancing patient satisfaction and outcome while ensuring continuity of care (D'Amore et al., 2011, p.249). In this case, the follow-up phone calls and follow-up appointments with primary care physicians will be implemented as part of the health plan for improved patient outcomes through reducing readmission rates. These phone calls will be made by trained nurses and appointments held with primary care physicians in an appropriate and convenient setting for the Medicare and Medicaid patients.

These measures of post-discharge care will achieve desired goals and objectives by providing education and support to patients. During this process, the primary care physicians and nurses will address any emerging issues associated with the patient's condition. They will also educate patients on appropriate self-management measures, lifestyle changes, and compliance with medications. As a result, patients will adhere to prescriptions for medications and take necessary measures to avoid exacerbations and unprecedented events. This will eventually contribute to reduced readmission rates by preventing patients' re-hospitalization.

Rationale for Proposed Solution The proposed solution was selected because of evidence in current literature and studies that adequate and effective post-discharge care helps in lessening the rate of re-hospitalization of patients, especially those with chronic diseases. According to Constantino et al. (2013), post-discharge telephonic calls and care have helped in lessening the number of readmissions and emergency room visits for Medicare patients (p.310). The interventions help in achieving this through increasing visits to physicians' office, which implies that these patients seek help from physicians resulting in avoidance of re-hospitalization.

The case for this proposed solution is also supported by vital evidence in literature that non-medical risk factors play a major role in early readmission of Medicare and Medicaid patients to hospitals (Iloabuchi et al., 2014, p.489). Implementation Logistics The integration of this proposed change or solution into the existing organizational structure, culture, and workflow will entail changing the organization's policy and operating procedures. The organization's leadership will develop a policy change in which this proposed change is included as a fundamental component of its health care processes and procedures.

Moreover, the leadership will develop a framework for conducting staff education and providing necessary resources for implementing the proposed change. The establishment of this framework will include providing necessary educational materials and technological and assessment tools for the training and implementation process. Nurses will work with their supervisors to execute the proposed solution while documenting any emerging issues or concerns during execution. Nurses and supervisors will provide important feedback, which will be used in evaluating the effectiveness of the solution relative to desired goals and expectations.

In collaboration with the supervisors, the organization's leaders will be responsible for initiating, executing, and assessing the implementation of this solution. Resources Required for Implementation Apart from ensuring the organization's leaders, supervisors, and nurses are responsible for implementing the proposed solution, necessary resources will be provided. These necessary resources for implementation include educational materials, assessment tools, and financial resources. The educational materials include pamphlets, handouts, posters, and PowerPoint presentations whereas assessment tools include surveys, technology, and questionnaires.

The pre- and post-implementation tests and surveys will be conducted to evaluate the effectiveness of the proposed solution in relation to desired objectives. Monetary resources will be utilized in conducting staff education, data collection and analysis, purchasing important educational materials, and for execution and analysis. In conclusion, readmission of Medicare and Medicaid patients within 30 days after discharge has become a major issue that is largely attributable to disease progression and ineffective post-discharge care.

Since most of these readmissions are influenced by non-medical risk factors, this proposed solution seeks to address the problem through follow-up telephonic calls and follow-up appointments with primary care physicians after patient discharge.

Evaluation Plan Proposed procedure: Initiating a new staff to fasten and improve the delivery of the services to the patients and hence aiding in the program to avoid readmission of them Methods to Evaluate The program to be initiated will require equitable measures being undertaken to prevent poor delivery of services to the patients, which often initiates their readmission.

The change of staff is intended to bring some alterations in the way in which services are delivered to the patients, the quality of services being delivered, and the time within which the services will be delivered. The new staff will have a renewed mechanism of operation where they will be expected to deliver to the best of their abilities, initiate measures to ensure their satisfaction, and put in place every measure that ensures that they have managed to deliver the best services at all times.

Regular Staff Environment Study The environment of work plays a critical role in influencing the nature of the services delivered to the patients. The working environment will constantly be improved followed by regular study and analysis of the best approaches needed for the staff to deliver to their best possible. Regular study of the staff-working environment will help boost staff confidence, satisfaction, and freedom to deliver.

Regular Staff Working Facilities & Skills Study It is important to improve the facilities used by the staff to deliver the Medicare and Medicaid services. The facilities will be offered regular upgrading and improvement as a way of ensuring their optimal delivery of quality if services as they are used by the staff. The facilities will be regularly maintained and serviced so that staff members get the chance to deliver as much as they want. Moreover, the skills of the staff will be rejuvenated after a considerable period.

For instance, the staff members will be taken through different seminarian proceedings and engagement that aid them to improve service delivery, while taking up progress records that will beckon further improvement (Cisneros, 2015). Training and other skill-imparting programs will be regularly initiated as a way of enabling the new staff to be engaged practically and theoretically as they work towards delivering the best of the services to the patients.

When the patients have received the best of the services using the most appropriate and skill methods, they have a less chance to engage in readmission based on the states of their health There are several things that a regular checkup and impartation of facilities and skills upon the workers will work towards improving the services received by the patients.

The improvement of the working facilities and the skills of the staff will enable them to be influenced to increase their concentration and want to deliver at best to the patients. The skills will be used as a way of measuring the effects they have on the improvement of the service delivery to the patients, and the subsequent patient activity in recovering.

What is essential in such a case is to ensure that the patients have received the best services that will enable them to achieve high standards of health as intended. Monitoring Staff Attitudes & Behaviors The attitudes and the behaviors of the staff will be monitored using check tools like the questionnaires and interview schedules. These tools will reveal the innate perceptions, feelings, reactions, and intentions contained by the staff members. These attributes will then be assimilated into the improvement plans (Cisneros, 2015).

Assessment & Evaluation Initiation The changes initiated will be monitored regarding their contributions, their certain changes they will result from the results of the services offered, and the general reaction of the patients and the staff upon these new things in place. The programs will involve regular placement of the changes and the contributions made by the changes (In Mason et al. 2015). Patient Response Collection Patients will be instrumental in eliciting the best approaches to realizing the success of the programs initiated to reduce readmission of Medicare and Medicaid patients.

The patients play a critical role in giving first person responses that suggest the feedback of every contribution made by the staff in meeting the needs of the patients. Furthermore, the patients must indicate their level of progress before and after admission. The new things or changes that have happened to their health and what can be done best to deliver better services to the rest of the patients must be considered as essential factors.

The final thing that will be done to ensure the assessment and monitoring have been done is to have a regulated documentation of every activity or service delivered, and the subsequent feedback. Such a step will ensure that the program has been implemented to the latter. Variables to be Assessed The environment of work Working facilities and skills in place Staff attitudes and behaviors Performance feedback Patient attitudes and perceptions The project will have its members being educated and informed through different tools of training and interaction.

These tools will include PowerPoint slides, questionnaires, and interview schedules, among others. These tools will play a critical role in enabling the program to be implemented, and feedback generated as a way of establishing measures to ensure equitable progress (In Mason et al. 2015). Disseminating Evidence Research studies are not ends in themselves. They are not designed, implemented, and completed for their own sake. They are undertaken to identify problems, promote a greater understanding of the issues involved, and present recommendations to resolve the problem based on the evidence.

Thus, equally important as ensuring the integrity and reliability of the research tools, methods, and process would be the dissemination of the research outcomes. This should lead stakeholders to take action and address the issues which were examined in the study. The dissemination of evidence achieves three main objectives: it increases the number of people who see the evidence; it motivates people to apply the evidence, as well as enabling them to use it (U.S. Department of Health and Human Services, 2013).

Stakeholder Project Dissemination Strategy In a small community, like a hospital or a similar facility, the best way to disseminate findings would be to present them directly to stakeholders. For instance, the researcher can invite stakeholders to a forum to discuss research findings. This sets the tone for a deeper discussion about the implications of the research, and the usefulness of implementing the recommendations made.

The researcher can choose to present the findings initially to the hospital leadership so that he could seek their support and approval in rolling out the proposals based on the results of his research. This will ensure that the proposals will already have the support of the hospital leadership even before they are presented to other stakeholders in a general meeting.

Nursing Community Project Dissemination Strategy The nurse may also present his research findings during a professional conference so that nurses from other institutions can be made aware of the problem, research results, and the solutions proposed by the researcher. When possible, the researcher can choose to publish his research in a publication geared for nurses so that the nursing community can benefit from his findings. Conclusion There are avenues available to the nurse to disseminate the results of his research.

It is important to reach immediate stakeholders because their cooperation is essential to the resolution of the problem identified in the study. At the same time, the nurse should be ready to reach out to the nursing community because other institutions might be dealing with the same issues. Multi-establishment collaboration would benefit the nursing community as a whole. Review of Literature Readmissions of various groups of patients have financial ramifications for hospitals.

It is very serious when a hospital is denied reimbursement because of the type of care that was provided by the institution. Readmission of a patient can be a reflection of the care that the patient previously received. There are many studies out there that has looked at the many dangers/issues associated with readmission. The literatures below will address the importance of post-discharge follow-up appointments as well as a post- discharge phone call. McCormack, R., Michels, R., Ramos, N., Hutzler, L., Slover, J. D., & Bosco, J. A.

(2013, January-February.) Thirty-day readmission rates as a measure of quality: causes of readmission after orthopedic surgeries and accuracy of administrative data. Journal of Healthcare Management, 58(1), 64-76. This article found that having community-based case management (CBCM) adequately reduced the readmission rate and noted its impact on budget, client results and satisfaction scores. This literature analyzed many articles on CBCM published between 2000 and 2013. It concluded that community case managers should definitely be included in the discharge planning.

Administration and management teams will need to be given more facts about community- based case management." Harrison, P. L., Hara, P. A., Pope, J. E., Young, M. C., & Rula, E. Y. (2011, February 14). The impact of post-discharge telephonic follow-up on hospital readmissions. Population Health Management, 14(1), 27-32. A substantial percentage of hospital readmissions are avoidable through proactive discharge planning and great follow-up. The research is based on data of insured patients, to determine if follow-ups after discharge had any effect on healing.

The article did find that the constant follow-ups did reveal lower readmissions, therefore hospital administrators should take this into consideration, and make the proper arrangements. D'Amore, J., Murray, J., Powers, H., & Johnson, C. (2011, November 5). Does telephone follow-up predict patient satisfaction and readmission? Population Health Management, 14(), 249-255. Patients who did not receive the proper readmission discharge pertaining to their follow- up appointments was slightly higher than those who had a scheduled visit with their primary care physician.

The research was based on facts collected over a year's time across multiple nursing departments whom regularly made those discharge phone calls. The data revealed that reaching out to a patient once they are discharged is a consistent way to lessen chance of readmission within 30 days from discharge. Iloabuchi, T. C., Mi, D., Tu, W., & Counsell, S. R. (2014, March). Risk factors for early hospital readmission in low-income elderly adults. Journal of the American Geriatrics Society, 62(3), 489-494.

The next literature examines issues that are not medically risk related among a certain community for returning to the hospital. This research looked at individuals that are 65 years of age and who fall below a certain income level. The research showed that there are various factors related to readmissions, such as the patient's level of happiness in regards to the services received from the doctor.

This is important for the nurses and doctors because it will help them realize how important their role is when it comes to elevating the care they are providing. DePalmaXu, H., Covinsky, K. E., Craig, B. A., Stallard,, G., E., Thomas III, J., & Sands, L. P. (013, J2une). Hospital readmission among older adults who return home with unmet need for ADL disability. Gerontologist, 53(3), 454-461.

This literature found that when hospital staff fall short in meeting the ADL of patients, there is an opportunity for them to be readmitted within 30 days following discharge. The study found a connection between unmet ADL's and readmission. ADL's has proven to be a very important part of a patient's recovery, so it's imperative that these issues are addressed prior to discharge. Graham, L. E., Leff, B., & Arbaje, A. I. (2013, February). Risk of hospital readmission for older adults discharged on Friday. Journal of the American Geriatrics Society, 61(2), 300-301.

This literature showed that the chances of being hospitalized all over again for those who are discharged on a weekend is higher. A closer analysis believes that this may occur because there may not be enough time for planning and sufficient education. Leaders in the hospital should ensure that the nurses are educating the patients about their disease process starting on day one. The earlier the patient and their families are educated the better, therefore we will decrease the chance of them being readmitted. Costantino, M.

E., Frey, B., Hall, B., & Painter, P. (2013, November 5). The influence of a post discharge intervention on reducing hospital readmissions in a Medicare population. Population Health Management, 16(5), 310-316. This article displays a connection among the follow-up phone calls and the readmissions. It is important because it exhibits that the sooner that the hospital staff reach out once the patient is discharged, the quicker intervention can take place in the outpatient setting; therefore, preventing readmission.

The writer assessed the facts of the patients who did receive a follow up call to the facts obtained from a control group. Timing plays such an important factor from the day of discharge until the next contact to prevent another trip to the hospital. Wong, F. K., Chan, M. F., Chow, S., Chang, K., Chung, L., Lee, W., & Lee, R. (2010, December). What accounts for hospital readmission. Journal of Clinical Nursing, 19(23/24), 3334-3346.

The above article found that the most important factor in hospital readmissions is the way patients view their own health. The more a patient understands their health, the more likely they are to follow-up. This suggested that each patient should understand their health assessment and voice their concerns so they can be provided with the information that they need prior to discharge, so that they can be avoid returning to the hospital. Providing the patients with what they need is key so that they can thrive in the community.

Walraven, C., Jennings, A., & Forster, A. J. (2012, December). A meta-analysis of hospital 30-day avoidable readmission rates. Journal of Evaluation in Clinical Practice, 18(6), 1211-12118. Research shows that less than 1 in 4 hospital readmissions is preventable. The writer used different databases to pinpoint different ways on how this could've been avoided. This negates any reflection of poor care on the hospital. Kelly, M. D. (2011, March). Self-management of chronic disease and hospital readmission: a care transition strategy. Journal of Nursing & Healthcare of Chronic Illnesses, 3, 4-11.

The above reading is an evaluation of present literature displaying the factors with the most impact on readmission when it comes to taking responsibility for their own healthcare needs. It should be the responsibility of the patient to follow up, take their medications as prescribed and monitor simple things such as their blood pressure or glucose levels. This article stresses the importance of self-care. Hansen, L. O.,.