Running Head: PREVENTING REHOSPITALIZATIONS 1. Preventing Re-hospitalizations

Transcription

1 Running Head: PREVENTING REHOSPITALIZATIONS 1 Preventing Re-hospitalizations Rebecca Dick, Julie Erickson, Amber Goetz, Marijo Johnson, John Richardson Ferris State University

2 PREVENTING REHOSPITALIZATIONS 2 Abstract This paper is written to review and analyze the need to develop a plan for quality initiatives for prevention of re-hospitalizations. Negative effects of re-hospitalizations will be reviewed, including health care financial burdens and poor quality outcomes. A plan will be developed to identify the team members necessary to implement the plan, data collections measures, establish desired outcomes and a method to evaluate the outcomes. Within this quality initiative, methods to decrease re-hospitalizations will be reviewed for effectiveness based on prior studies. After reviewing the current research on preventing hospital readmissions, a plan will be developed to reduce re-hospitalizations and evaluate progress.

3 PREVENTING REHOSPITALIZATIONS 3 Preventing Re-hospitalizations Allocation of medical resources, financial resources and quality outcomes are major concerns considering the amount of American dollars spent on healthcare. The United States spends more dollars on healthcare than any other country in the world but continues to rank 37th when it comes to best healthcare outcomes (Campbell & Campbell, 206, p. 17). Preventing rehospitalization will assist in preserving healthcare funds, as well as improve patient outcomes and quality of life. In 2009, the Center for Medicare and Medicare Services (CMS) reported almost 18 percent of Medicare patients are readmitted within 30 days of discharge, and 13 percent of the readmissions $12 billion worth were potentially avoidable (Atlantic Information Systems, 2008, p.1). Frequent hospital admissions can increase depression, create loss of control in one s life, signify medical instability and interrupt family normalcy. Jane Brock M.D., medical officer for the Colorado Foundation, (2008) says readmissions are the intersection of three things we care about: cost, quality and patient safety. (Atlantic Information Systems, p.1). The development of a quality improvement initiatives to prevent hospital readmissions is critical to health care in the United States; to provide optimal wellness for patients and ensure appropriate allocation of healthcare resources. The implementation of a successful process to prevent re-hospitalizations includes identifying an interdisciplinary team, implementing evidence based practice, establishing goals and evaluating program outcomes. Interdisciplinary Team Approach Providing holistic care requires an interdisciplinary team approach. When considering the prevention of hospital readmission, the team must include members within the acute care setting and the outpatient care setting. The Atlantic Information System (2008) states that preventing hospital readmissions is about taking care of people with ongoing problems of chronic illness and frailty and if not done well, the patient ends back in the hospital (p. 1). The

4 PREVENTING REHOSPITALIZATIONS 4 acute care discharge team, including social workers, case managers and nurses, provide discharge planning based on individualized patient needs which include personal barriers such as transportation, lack of family support, and financial resources. Arrangements for medical follow up services will be planned out before discharge from acute care. In addition to the hospital discharge team, follow up care providers must be committed to identifying patients who have been recently discharged from the hospital and need urgent and/or frequent monitoring. Continuation of care is critical to the prevention of hospital readmissions. Appendix A reflects a sample discharge of the continuing care transition process which may assist with diminishing hospital readmissions. Data Collection Methods In an effort to determine the exact problem, a root cause analysis of the issue will first be conducted using a limited patient population in a specific community. The use of a flowchart will help determine which patients need closer follow up after discharge and the exact method by which the health care team will facilitate the care. If the literature reveals that patients originally admitted with pneumonia and CHF are more likely to be readmitted within 30 days, it would be beneficial to closely monitor these patients after discharge. Outcomes The goal is for patients to obtain wellness and quality of life regardless of chronic conditions. By decreasing hospital admissions among patients with chronic illnesses, people will be able to manage their conditions more economically for themselves and the community. Every patient admitted to the hospital with pneumonia or CHF will be visited by an outpatient provider within three days of discharge from the acute care setting. After determining that this standard

5 PREVENTING REHOSPITALIZATIONS 5 of care actually decreases hospital readmission within 30 days, it will be implemented to be a standard of care in every patient with these conditions. Strategies to Prevent Hospital Readmissions Research shows that implementing strategies and processes, such as Transitional care programs, can be effective in reducing hospital readmissions. Boutwell, Griffen, Hwu & S. Shannon, (2009) state rates of avoidable re-hospitalizations can be reduced by improving core discharge planning and transition processes out of the hospital; improving transitions and care coordination at the interfaces between care settings; and enhancing coaching, education, and support for patient self-management (p. 2). Transitional care programs require commitment from the hospital medical providers as well as outpatient providers. Hitt, (2011) describes a three month study which includes an initial visit from an advance practice nurse, within 3 days of hospital discharge, which focused on defining goals; exploring the nature, duration, and severity of medical diagnosis and co morbid conditions; reviewing health behaviors and skills; and identifying the availability of social support (para. 8). An additional 8 visits were conducted by the advanced practice nurse over the course of three months, with additional support available seven days per week focusing on disease management, goal setting and patient and family education. A 48 percent reduction in the rehospitalizations rate at 30 days was noted (Hitt, 2011, para. 8). Identifying programs and processes gives opportunity to initiate programs to improve quality outcomes in the community. The strategic plan to reduce hospital readmission, improve quality outcomes and improve the use of healthcare resources will include Transitional care models utilizing health providers in acute care and outpatient settings. In this quality improvement initiative, acute care providers, nurses and case managers will develop an individualized discharge plan with patients and

6 PREVENTING REHOSPITALIZATIONS 6 families. Outpatient and acute care providers will collaborate in a joint initiative to decrease readmission rates. The Atlantic Information System (2008) cites the Colorado Foundation for Medical Care identified by addressing medication management, keeping accurate patient medical records, follow up care and identifying signs and symptoms of decline in condition and how to respond to decreased hospital readmissions within thirty days by fifty percent (p. 2). The inpatient health providers will initiate the discharge plan which includes specific interventions to deter readmissions. Nurses and case managers will develop a discharge plan including a follow up appointment with an outpatient provider. The appointment will be made prior to discharge and noted on the discharge instructions. The discharge instructions will include a medication list in lay person terms. This medication list with be reviewed with the patient and the family or significant other. New medications or dosage changes will be specifically reviewed and noted on the discharge instructions and will be called to the pharmacy prior to discharge. Patients who do not have a primary care provider will be referred to a provider or an appointment will be made at a local clinic offering services pertinent to the patient s condition. Follow up needs, directed for the patient as well as the outpatient provider, will be clearly identified on the discharge plan. The inpatient discharge planner will identify and address barriers to the discharge plan. Transportation arrangements will be made as needed. Barriers to obtaining medication such as insurance or transportation will be identified and resolved. The transition from the inpatient setting will be smooth and educational with clear instructions for the patient and the outpatient provider. Discharge instructions and follow up appointments will be faxed by the inpatient provider to the outpatient provider. An emergency number will be given to the patient or family for questions and concerns between the time of discharge and the outpatient appointment. When possible, the outpatient appointment will occur

7 PREVENTING REHOSPITALIZATIONS 7 within 3 days. A home care provider may be used to bridge the gap between discharge time and the follow up appointment. In addition to the 24 hour support number, pamphlets or fact sheets will be provided for patients. The information will contain potential high risk situations and techniques to manage the situation at home and when to call the outpatient health care provider. The outpatient provider must be committed to timeliness provisions for services of discharge patients. The preferred timeframe for initial consultation after discharge is within three days; however, this may not be possible in many situations and a homecare provider may be used until an appointment occurs. The plan for the initial appointment includes medication reconciliation and a complete patient assessment as well as signs and symptoms of decline and improvement. Continued education will be provided to the patient and caregiver on optimal wellness related to medical conditions. Support groups will be identified and referrals made. In the initial 3 months post hospital discharge, the patient will be seen a minimal of 8 times. A care plan will be created at the initial post discharge visit identifying individualized patient goals. The focus of follow up visits will include continued medication reconciliation, education and goal attainment. Conclusion Incorporating the Transitional Care Model to the discharge of patients from the hospital can increase patient satisfaction, safety and quality of care. New standards of care can help streamline the healthcare process and facilitate better patient outcomes. Using evidence based practice and continuing to evaluate best practices; the health care system can evolve and grow so that it can better serve the population more economically and efficiently.

8 PREVENTING REHOSPITALIZATIONS 8 References Atlantic Information Systems Incorporated. (2008). CMS targets readmission through payment audits, coaching model reduces rates. Retrieved from Boutwell, A., Griffin, F., Hwu, S., & Shannon, D. (2009). Effective interventions to reduce rehospitalization: A compendium of 15 promising interventions. Institute for Healthcare Improvement. Retrieved from Campbell, T. C., & Campbell, T. M. (2006). The China study. Dallas, TX Hitt, E. (2011, July 26). Innovative interventions decrease rehospitalization rates. Medscape Medical News. Retrieved from

9 PREVENTING REHOSPITALIZATIONS 9 Appendix A Initiation of discharge plan in hospital Does the patient have financial and transportation y e s No Social Services: 1. Assist with arranging transportation to follow up visits. 2. Ensure financial ability to obtain medications. Care manager 1. Arrange initial follow up appointment with continuing care provider within 3 days 2. Fax information provider. 3. Review discharge instructions and medications with patient and family / significant other. Emphasize medication changes since admission. 4. Ensure patient has discharge information for emergency care related to diagnosis. Upon initial visit, continuing care provider: 1. Reconcile and review medications. 2. Provide education to care for medical diagnosis and manage potential complications. 3. Complete comprehensive assessment. 4. Initiate referrals for dietary follow up and / or other specialty services. 5. Implement a schedule for follow up appointments over the next three months Collect Data and evaluate Outcomes

10 PREVENTING REHOSPITALIZATIONS 10 Grading Rubric for Leadership Strategy Analysis Quality Improvement Process POINTS POSSIBLE POINTS AWARDED Comments Introduction: Background and 5 purpose for quality and safety initiatives. Discusses the leadership 5 strategy to be performed. Identify Clinical Need: Identifies a 10 clinical activity for review. Provides an analysis of the problem using 10 current nursing literature. Designs an Interdisciplinary Team: 10 Identifies and analyzes the inclusion of team members involved with the 10 problem. Data Collection Method: Chooses 10 and designs a method of data collection. Provides support for 10 collection method as a leadership strategy. Establishes Outcomes: Identifies a 5 standard of care (goal for improvement) that reflects evidencebased 5 practice. Implementation Strategies: Selects 10 and describes a process for implementing change. Integrates 10 theory and EBP to support the identified process. Evaluation: Identifies and designs a 10 method for measuring improvement. Integrates theory and EBP in 0 analyzing improvement. Scholarship: Integrates evidence of 10 theory, current evidence-based research and information 10 management resources to support decisions. Sentence structure, spelling, 30 grammar & punctuation; APA 29 Format TOTAL POINTS Excellent work! Your team is comprehensive and collaborative. You obviously put much time and research to create a well thought out plan. Since you did not include an evaluation section, it was not clear to me your evaluation method for measuring improvement. If you can demonstrate that to me by highlighting it in the paper, points can be added.