Rehabilitation Improvements through Implementation of Improved Discharge Processes to Decrease Readmission
Section One: Overview of the Evidence-Based Project
Introduction
High quality patient care is considered an effective way of reducing hospital re-admissions among hospitalized patients (Hubbard & McNeil, 2012). Among patients with chronic illnesses or injuries, Hubband and MNel (2012) note that rehabilitation therapies are critical in facilitating the restoration of their health condition. To enhance the recovery process of hospitalized patients, Hager (2010) posits that discharge planning is an important step in realizing reduced readmissions of hospitalized patients. Discharged patients require prolonged care after leaving the hospital wards to help boost their full recovery, especially in the modern era when the duration of hospital recovery has been largely reduced when compared to the rates in the previous century (Popovic & Kozak, 2000).
Popovic and Kozak (2000) note that a considerable number of discharged patients suffer from health condition deterioration, prompting readmissions after their discharge from hospital in cases that could be avoided with effective discharge planning. Most of the adverse conditions witnessed after discharge are as a result of errors in medical prescriptions and follow by the relevant personnel to follow-up on unresolved problems (Boutwell & Hwu, 2009). Discharge planning comes in handy in helping discharged patients recover faster through processes such as the dissemination of discharge medication education to patient care givers like family members (Forster, et al., 2004). Nurses are the medical practitioners who are mostly mandated with the task of ensuring that hospitalized patients receive efficient care. As such, it is their responsibility to ensure that the care takers mandated with overseeing patients after discharge have sufficient skills to ensure that the patients regain full recovery (Hager, 2010). Hager (2010) asserts that failure to maintain high levels of patient care distorts the patient recovery process leading to avoidable hospital readmissions. Chronic diseases have been highly prevalent in the modern century prompting the need for highly coordinated patient care to help decrease readmission incidences by enhancing the quality of patient care (Robison, 2010). Therefore, it is important that best practices and efficient patient care models be adopted to help realize improved rehabilitations and decreased patient readmissions across various hospitals.
Problem Statement
Hospital rehabilitation is a very important exercise that provides an adequate environment for mitigation of various diseases such as chronic illnesses, injuries, among others. Through hospital rehabilitation, patients receive specialized care that helps enhance their recovery process (Hager, 2010). However, upon discharge, patients are equally expected to continue receiving high quality care until their final recovery which unfortunately does not happen very often. Due to the advancement of medical technology and other best practices, the quality of care provided to patients is usually high level hence leading to reduced days of hospital stay, a move that is economically friendly to the patients as it decreases the hospital costs (Hager, 2010).
To help ensure the discharged patients maintain impressive recovery processes, discharge planning guides their medication and care processes, hence, reducing the possibilities of avoidable readmissions (Forster, et al., 2003). The rate of hospital readmissions is however high due to the lack of efficient discharge plans leading to instances of family members and other caregivers lacking knowledge of how to guide the medication process of the patients after their hospital discharge (Hubbard & McNeil, 2012). As a result, the discharged patients fall into instances of inability to continue their recovery process uninterrupted whenever they are discharged to caretakers who are not able to help them abide by the medication prescriptions presented unto them upon discharge (Hager, 2010). This condition prompts this study to endeavor to ascertain the impact of improved discharge processes in reducing the rate of hospital readmissions, hence, enhancing the quality of rehabilitation care. Thus, it is important that this study brings forth reliable factors with regard to how best to reduce hospital readmissions with improved discharge programs.
Purpose Statement and Project Objectives
Most rehabilitation facilities provide essential medical support to patients with chronic illnesses or injuries capable of causing disabilities. It is the expectation of the rehabilitation facilities to ensure that the patients treated do not get re-admitted for at least six months after discharge, an indication of high quality patient care (Hager, 2010). The creation of important discharge programs helps ensure that the discharged patients face smooth transition periods from the hospital setups back to their homes (Forster, et al., 2003). Therefore, the purpose of this study is to ensure that patients receive sufficient care in their post discharge periods to help ensure they do not get re-admitted soon after their hospital discharge. The development of efficient discharge plans just after patients are admitted is one of the best ways to realize a patient centered discharge model through which they can continue receiving highly standardized care to help enhance their recovery, leading to reduced incidents of hospital readmissions (Hager, 2010).
The high rates of hospital readmissions can be attributed to the lack of sufficient discharge programs through which the discharged patients can continue adhering to the prescribed medication instructions, boosting their recovery process (Hager, 2010). It is important that discharge programs be instituted in all rehabilitation facilities due to the delicate state of most of the chronic diseases which require consistent medications and adherence to prescribed instructions to help ensure stable patient recovery rates. The realization of best practices with regard to the post-discharge handling of patients is thus an important focus point in an attempt to help ensure that patients in rehabilitation centers do not get re-admitted just after discharge (Hubbard & McNeil, 2012). The amount of available evidence and studies is not sufficient, hence, the need for this study to provide a reference base with regard to the use of discharge plans in enhancing the quality of patient care in rehabilitation centers and after their hospital discharge.
In this study, discharge planning will begin immediately after admission and will continue throughout the admission period to help ensure that the caregivers who will take-up after discharge are conversant with the medical needs of the patients. The ADAPT standardized measurement tool will be used in the analysis of the influence of discharge planning in reducing the rates of hospital readmissions. Through this tool, the patient transition process from the rehabilitation centers to the community setting will be analyzed to help ensure that patients keep receiving high quality care. The main components of the ADAPT analysis tool will be family education and team collaboration to help ensure that patients receive highly standardized care.
Significance/ Relevance to Practice
Hager (2010) notes that in the past, family members of discharged patients have complained about their ability to provide sufficient patient care after discharge. This was prompted by their lack of knowledge of how best to care for the patients especially in ensuring they meet their medically prescribed needs, thus prompting the need for provision of discharge guidelines to caregivers upon hospital discharge of patients. Patients have also complained about their ability to recall medical instructions, making it highly important that all post-discharge stakeholders receive specialized discharge education to help ensure that the patients recover fully (Forster, et al., 2004).
Most of the patients admitted to rehabilitation centers are usually the ones suffering from chronic illnesses that often require specialized high quality care to boost recovery and reduce on the rate of hospital readmissions (Hubbard & McNeil, 2012). The cost of readmissions when treating chronic ailments is very high and can severely stretch the financial coffers of patients while also reducing the ability of hospitals to access reimbursements based on their rates of readmissions (Marek et al., 2010). Hospitals with few readmissions meeting some set threshold receive stipulated financial reimbursements as a motivation and recognition of their good work. This study shall thus help provide mechanisms through which both the healthcare organizations and the patients shall gain financially. Through the use of the discharge plans, patients and their community accomplices receive standardized guidance on how to continue abiding by the set medication prescriptions after their hospital discharge (Hager, 2010). Thus, elaborate discharge plans provide guidance for the patient transitions from the hospitals to their homes in a smooth manner to help ensure that the patients do not get adversely affected in the process.
Through the discharge plans, the patient rehabilitation process is boosted as they do not worry about the quality of care they will receive at their homes as all the care stakeholders get briefed on what they are expected to do to help the patient fully recover (Hubbard, & McNeil, 2012). Full patient recovery means no hospital readmissions soon after discharge and as a result, the hospitals can easily receive financial reimbursements from the government for their quality of care accorded to patients. The study will also contribute to the enhancement of the patient satisfaction levels on matters to do with the discharge process. In modern medical practice, all operations are patient centered and when they are not satisfied with the rehabilitation and discharge processes, it could portray the hospital badly resulting in adverse effects such as the lack of financial reimbursements.
The study will additionally enhance the bond between patients and their families due to the increased knowledge of the need to maintain some level of care quality to help enhance recovery and avoid unnecessary hospital readmissions (Hubbard, & McNeil, 2012). Whenever the family members understand deeply the condition of their patients with stipulations on what to do to boost their recovery, their road to full recovery gets assured. The study will also contribute to the development of best practices in medical care as it shall provide the guidelines through which hospitals can improve their care to rehabilitation patients in addition to reducing instances of patient readmissions. Due to insufficiency in the quality of information available with regard to the enhancement of patient satisfaction levels through the development of effective discharge plans, this study will help enhance the available literature and form a reference base for other future studies. Hence, this study will be very significant to the current nursing practice processes and will help enhance the development of various policies targeting the enhancement of the quality of patient care in addition to boosting the patient satisfaction levels.
Project Question
The guiding project question is: Will the use of developed discharge planning, team collaboration and family engagement effectively decrease patient readmission to the hospital or other healthcare facility for the same diagnosis within a six-month period?
Evidence-based Significance of the Project
The study will use the IOWA model of using team collaboration to help improve patient outcomes in dissemination medication to the patients and their family to help have an efficient transition from the hospitals to the community and home set-ups. This will help reduce the probability of incurring hospital readmissions within six months after patient discharge. The project shall, thus, be very crucial to the overall realization of reduced hospital readmissions in healthcare facilities.
Implications for Social Change in Practice
Patient care is the current operational focus in modern medical practice. Nurses play a critical role in keeping patients satisfied and as a result, their activities directly matter to the perception of the patients. Through this study, the importance of team work under the facilitation of nurses shall be exhibited through the care coordination process pitting patients, their families/caregivers and the nurses in a bid to achieve enhanced patient care and reduced readmissions for a period of six months after discharge. Thus, this study shall bring forth the importance of team work in healthcare service provision to help achieve improved patient care in addition to boosting the level of patient satisfaction.
Based on social justice principles, the nurses will also bring forth the need for everybody to get involved in advancing the welfare of others through concern and collaboration. As evidenced in this study, nurses are able to use education as a tool to boost patient recovery and bring cohesion between the patients and their families through relevant information sharing (Hager, 2010). Nursing practice highlights the need to care for others regardless of their condition and social backgrounds in an effort to help them recover their health.
Definition of Terms
Caregiver – Refers to a person entitled with the care of a patient after discharge (Hubbard & McNeil, 2012).
Teamwork – Refers to the coordination of efforts from various professionals or participants to achieve some set goal (Hubbard & McNeil, 2012).
Nurse – A healthcare service provider mandated with the provision of care to parents treated by doctors (Hager, 2010).
Discharge – Refers to the process of releasing patients from hospital beds upon their recovery (Hager, 2010).
Readmission – Is a term used to refer to the process of having patients gets back to the wards for hospitalization after initial discharge (Hubbard, & McNeil, 2012).
Re-Hospitalization – refers to the process of having patients admitted to the hospital soon after discharge (Boutwell & Hwu, 2009).
Recovery – Is a term used to refer to the process of patients regaining their health after receiving medical treatment (Boutwell & Hwu, 2009).
Rehabilitation – Refers to the process of treating persons with chronic illnesses or disabilities in medical facilities (Hager, 2010).
Transition – Is a term that refers to the process through which movement is done from one location set up to another (Hubbard & McNeil, 2012).
Assumptions and Limitations
This study is based on various assumptions such as; the study assumes that the study participants are of sound mind and can give independent opinions. The study assumes that all the participants have been admitted at the hospital wards for some period of time. The study also assumes that all the participant patients are at a risk of re-admission. These assumptions guide the study in carrying out its objective of evaluating the impact of discharge planning in reducing hospital readmissions. The main limitation expected in this study is the use of a small number of participants in both the experimental and control groups in addition to the tedious process of ensuring that all the study participants are followed up for a period of six months. Additionally, the study faces the uncertainty of the survivor of the discharged participants as some may die before getting readmitted all making it through the study observation period.
Summary
Patient care is an integral part of modern medical practice and much effort is concentrated in ensuring that patients’ satisfaction levels are high in addition to ensuring high quality service delivery. Patients with chronic ailments in particular are a special group of patients that always require high quality of care both in the hospital setting and at the community or home setting. The medical requirements for patients suffering from chronic ailments are very specific and delicate, prompting the need for enhanced care at all times. However, this has not been the case in most cases as most patients have been observed to lack specialized care after discharge prompting their hospital readmission. The main reason for this occurrence has been observed to be the lack of proper transition instructions from the hospitals to homes and communities.
The use of discharge planning has been poised to help realize reduced instances of hospital readmissions through the dissemination of post-discharge care guidelines to both the patients and their home caregivers. This study has been touted to strongly help enhance the patient satisfaction levels in hospitals through the use of the discharge plans to help all stakeholders take part in ensuring the discharged patients receive high quality services in their home settings to help them recover fully. This study uses a six-month guideline to measure the readmission rate after discharge through the use of experimental and controlled groups. Overly, this study shall be very instrumental in guiding the dispensation of medical information to patients and caregivers in rehabilitation centers to help ensure no readmission takes place for same diagnosis for a period of six months after discharge.
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