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 an effective way of reducing rehabilitation center readmissions among hospitalized patients (Hubbard & McNeil, 2012). Among patients with chronic illnesses or injuries, Hubbard and McNeil (2012) noted that efficient rehabilitation therapies are critical in facilitating the restoration of patients’ health. To enhance the recovery process of patients in rehabilitation centers, Hager (2010) posited that discharge planning is an important step in realizing reduced readmissions of hospitalized patients. Discharged patients require prolonged care after leaving the hospital units to help boost their full recovery, especially in the modern era when the duration of hospital stays is lower than the rates in the previous century (Popovic & Kozak, 2000).
Popovic and Kozak (2000) noted that a considerable number of discharged patients suffer from health condition deterioration, prompting readmissions after their discharge from rehabilitation centers in cases that could be avoided with effective discharge planning. Most of the adverse conditions witnessed after discharge are a result of errors in medical prescriptions or their use and failure by the relevant personnel to follow-up on unresolved problems (Boutwell & Hwu, 2009). Discharge planning helps discharged patients recover faster through processes such as the dissemination of discharge medication education to patients and their caregivers (Forster et al., 2004). Nurses are the health care practitioners entrusted with the task of ensuring that hospitalized patients receive appropriate and timely care. As such, it is their responsibility to ensure that the caregivers who will be overseeing patients’ care after discharge have sufficient skills to enable patients to recover (Hager, 2010).
Hager (2010) asserted that failure to maintain high levels of patient care distorts the patient recovery process leading to avoidable rehabilitation center readmissions. Chronic diseases have been highly prevalent in the modern century prompting the need for coordinated patient care to help decrease readmission incidence 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 rehabilitation discharge processes and decreased patient readmissions in long-term care facilities (LTF) and skilled nursing rehabilitation facilities (SNF) within 6 months with same diagnosis. This Doctor of Nursing Practice (DNP) project will focus on ascertaining the discharge processes at rehabilitation centers to help ensure that patients are discharged with appropriate guidelines to avoid readmitting them with same illness within 6 months of discharge.
Problem Statement
Rehabilitation centers provide an adequate environment for improvement of various diseases such as chronic illnesses and injuries, among others. Through rehabilitation, patients receive specialized care that helps enhance their recovery process (Hager, 2010). However, upon discharge, patients must continue receiving high quality care until their final recovery. Due to the advancement of medical technology and other best practices, the quality of care provided to patients is usually high level leading to reduced days of hospital stay. This move is economically friendly to the patients and decreases hospital costs (Hager, 2010); however, much more focus needs to be placed on enhancing the discharge process to reduce avoidable readmissions.
To help ensure the discharged patients to recover, discharge planners guide their medication and care processes to reduce the possibility 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 about medications and other treatments or care guidelines after the patient leaves the hospital (Hubbard & McNeil, 2012). As a result, the discharged patients fall into instances of inability to continue their recovery process when caregivers are not able to help them abide by the medication prescriptions presented to them at discharge (Hager, 2010). This reality prompted this project to endeavor to ascertain the impact of improved discharge processes in reducing the rate of hospital readmissions. Thus, it is important that this project focus on best practices to reduce rehabilitation center readmissions through 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. The rehabilitation facility managers expect that discharged patients are not readmitted for at least 6 months after discharge, an indication of high quality patient care (Hager, 2010 ). The creation of evidence-based discharge planning programs helps ensure that the discharged patients face smooth transitions from the rehabilitation center back to their homes (Forster, et al., 2003). The purpose of this project is to ensure that patients receive sufficient care in their post discharge periods to help ensure no readmitted patients soon after their rehabilitation discharge. The development and implementation of targeted discharge plans just after patients are admitted is one of the best ways to realize a patient-centered discharge model through which patients can continue receiving standardized care to help enhance recovery and reduce incidence of hospital readmissions within 6 months of discharge (Hager, 2010).
The rehabilitation center attributes the high rates of readmissions to insufficient discharge programs through which the discharged patients can continue adhering to the prescribed medications (Hager, 2010). It is important that the rehabilitation center institutes discharge programs due to the delicate physical state of most of patients with chronic diseases who require consistent medication administration and adherence to prescribed instructions to facilitate patient recovery. The realization of best practices with regard to the post discharge handling of patients is an important focus in any attempt to help ensure fewer patients need readmission to the rehabilitation center after discharge (Hubbard & McNeil, 2012).
In this project, discharge planning will begin immediately after admission and will continue throughout the admission period to help ensure that the caregivers after discharge are understand and can carry out the medical needs of the patients.
The IDEAL standardized measurement tool will be used in the analysis of the influence of discharge planning in reducing the rates of rehabilitation center readmissions. Analyses conducted through use of this tool for data collection, ensures that patients receiving high quality care after the transition to home. The main components of the IDEAL tool are family education and team collaboration to help ensure that patients continue to receive highly standardized care upon discharge.
Nature of the Project
Significance/Relevance to Practice
Hager (2010) noted 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, and prompting the need for provision of discharge guidelines to caregivers upon discharge of patients. Patients have also complained about their ability to recall medical instructions, making it highly important that all postdischarge 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 suffering from chronic illnesses that often require specialized high quality care to boost recovery and reduce on the rate of rehabilitation center readmissions (Hubbard & McNeil, 2012). The cost of readmissions when treating chronic ailments is very high and can severely stretch the finances of patients, while also reducing the ability of rehabilitation centers to access reimbursements based on their rates of readmissions (Marek et al., 2010). Rehabilitation centers with few readmissions and meeting set thresholds receive financial reimbursement as a motivation and recognition of their good work. This project shall provide mechanisms through which both the healthcare organizations and the patients shall gain financially. Using the discharge plans, patients and their community caregivers receive standardized guidance on how to continue abiding by healthcare protocols and established medication regimens after discharge (Hager, 2010). Elaborating and communicating detailed discharge plans can provide guidance for patient transitions from the rehabilitation center to the home in a smooth manner to ensure safe and effective patientcare continues.
Nurses instruct Community caregivers on what they must do to help the patient fully recover (Hubbard & McNeil, 2012). Full patient recovery means no readmissions soon after discharge. The project will contribute to the enhancement of patient satisfaction related to the discharge process. Modern medical practice focuses operations on delivery of patient-centered care and when the patients and families are not satisfied with the rehabilitation and discharge processes, lower satisfaction scores will affect financial reimbursement for care provided.
The project will enhance the patient and caregivers’ knowledge about the need to maintain care quality to help enhance recovery and avoid unnecessary readmissions (Hubbard & McNeil, 2012). Family members enhance the recovery of patients at home when they understand how to support the recovery of the patient. The project will contribute to the development of best practices in health care, as it will provide guidelines through which hospitals can improve their care to rehabilitation patients in order to reduce 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 project will add to the available literature and may serve as a benchmark for future projects. The project will improve the current nursing practice processes in the rehabilitation center and will help enhance the development of policies to enhance the quality of patient care and boost patient satisfaction.
Project Question
The guiding project question is: Will the use of discharge planning, team collaboration, and family engagement effectively decrease patient readmission to the hospital or other healthcare facility for the same diagnosis within a 3-month period?
Evidence-based Significance of the Project
The study will use the IOWA model of team collaboration to help improve patient outcomes in dissemination of medication information to the patients and their family members to help transition from the rehabilitation center to the community and home. This collaboration will help reduce the probability of incurring readmissions within 6 months after patient discharge. The project will be crucial to the overall realization of reduced rehabilitation center readmissions in healthcare facilities and the recouping of costs associated with these readmissions.
Implications for Social Change in Practice
Patient-centered 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. Throughout this project, teamwork in care coordination with patients, their families/caregivers, and nurses will achieve enhanced patient care and reduced readmissions for a period of 6 months after discharge. This project will focus on the importance of teamwork (patient, family, and health care providers) in healthcare service provision to help achieve improved patient care after discharge and boost the level of patient satisfaction.
Based on social justice principles, the nurses will work with all stakeholders prepare and involve them in the care of discharged patients. As evidenced in this project, 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 caring for 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).
Discharge – Refers to the process of releasing patients from hospital beds upon their recovery. In this project, the discharge is from a rehabilitation center where patients continue to recover after an acute hospital stay prior to returning home (Hager, 2010).
Readmission – Is a term used to refer to the process of having patients go back to the hospital unit after initial discharge (Hubbard, & McNeil, 2012).
Rehospitalization – 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 best possible health after receiving medical treatment (Boutwell & Hwu, 2009).
Rehabilitation – Refers to the process of treating persons with chronic illnesses or disabilities in medical facilities to improve their ability to conduct activities of daily living in their home setting (Hager, 2010).
Transition – Is a term that refers to the process through which a patient moves from one location to another. The transition is usually from a higher acuity setting to a less acute setting for recovery (Hubbard & McNeil, 2012).
Assumptions and Limitations
The project assumptions include that the study participants are of sound mind and can give independent opinions, the participants will remain at the rehabilitation center for some time, and the participating patients are at a risk of readmission. 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 participants are followed up for a period of 6 months. Additionally, the project faces the uncertainty of the survival of the discharged participants. Some participants may die before completion of the 6-month observation period.
Summary
Patient care is an integral part of modern health care 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 require high quality of care both in the rehabilitation center setting and in the community or home setting. The medical requirements for patients suffering from chronic ailments are very specific and delicate, prompting the need for enhanced vigilance of care at all times. However, many patients and their caregivers have not been able to follow the specialized care plan after discharge prompting patient readmissions. The main reason for this occurrence is the lack of proper transition instructions from the rehabilitation centers and verification of the patient and caregivers’ understanding of and commitment to the plan after discharge to their homes and communities.
The use of discharge planning can reduce instances of rehabilitation center readmissions through the dissemination of postdischarge care guidelines to both the patients and their home caregivers. This project is expected to enhance patient satisfaction scores with the rehabilitation center 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 project uses a 6-month timeframe to measure the readmission rate after discharge using experimental and control groups. The project will be instrumental in guiding the healthcare education provided to patients and caregivers in rehabilitation centers to help ensure no readmission takes place for same diagnosis for a period of 6 months after discharge.
References
Boutwell, A., & Hwu, S. (2009). Effective interventions to reduce rehospitalizations: A survey
of the published evidence. Cambridge, MA: Institute for Healthcare Improvement.
Forster, A. J., Clark, H. D., Menard, A., Dupuis, N., Chernish, R., & Chandok, N (2004).
Adverse events among medical patients after discharge from hospital. Canadian Medical
Association Journal, 170(3), 345-349.
Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence
and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3), 161-167.
Hager, J. S. (2010). Effects of a discharge planning intervention on perceived readiness for
discharge. Doctor of Nursing Practice Systems Change Projects . Paper 2.
Hubbard, D., & McNeil, N. (2012). Improving medication adherence and reducing readmissions.
NEHI Issue Brief, 1(2012), 1-12.
Marek, K., Adams, S., Stetzer, F., Popejoy, L., & Rantz, M. (2010). The relationship of
community based nurse care coordination to costs in the Medicare and Medicaid programs. Research in Nursing and Health, 33(1), 235-242.
Popovic, J. R., & Kozak, L. J. (2000). National hospital discharge survey: Annual summary,
- Vital and Health Statistics No. 148. Hyattsville, MD: National Center for Health Statistics.
Robinson, K. (2010). Care coordination: A priority for health reform. Policy, Policies & Nursing
Practice, 11(4), 266-274.
For the DNP project proposal, delete the title and the running head. There is a title page in the DNP Template that should be used.
All references to the literature should be in the past tense.
Some place in this section it would be good to include the information from CMS about the percent reduction in reimbursement for readmissions.
Is this the CMS rule?
Add this section according to the DNP Checklist.
Be specific. What exactly is being measured and how is the reimbursement made?
This plan presupposes that all families are available and have the emotional, physical, and financial ability to undertake the care.
Readers should know this definition.
All authors need to be included. If there are more than seven authors, check your APA Manual for the correct formatting.
Is this a book or an article? Complete the reference.
Write out the title of the journal.
