¶ … 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...

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…