Team Based Transitions Of Care

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

Transition of care appeals to me the most in my practice as a case manager. When a patient gets admitted, the interdisciplinary team starts working on the discharge planning. I always wonder how can the team know for sure, that the patient is ready to be transitioned and how can we know for sure that the transition of care is safe and it would not be overlook?

Providing patients diagnosed with Congestive Heart Failure effective teaching can eliminate reoccurring hospitalizations. Patients are discharged with CHF and readmitted within 30 days. The information provided will examine the process of enhancing patient knowledge and provide additional resources essential for effective health care management. Research evidence provides data that proves patients who are diagnosed with CHF needs a variety of health care needs during admission and after discharge. The proposal will display an evaluation plan, implementation plan and a dissemination of the

In 2004, the Healthcare Effectiveness Data and Information Set (HEDIS) stated that “Kaiser Permanente Southern California (KPSC) region, where approximately 6,000 physicians in the Southern California Permanente Medical Group, and where approximately of 3.5 million adults and pediatric are treated, there performance was below the national 50th percentile”. (Kanter et al., 2013) Since the performance was below what they aspired to achieve, in 2005 KPSC recognized the potential to improve quality of care through providing complete care for patients who have chronic illness.

The Ultrasound technician will facilitate the abdominal ultrasound to produce images of the organs for interpretation.

Hospital discharge has been defined as “a systemic problem that can be characterized as a dangerous situation in which latent conditions exist such that sharp end individuals are set up to fail” (Anthony et al., 2005). Understanding this process is flawed warrants an investigation for a change in practice. Research has explored a variety of interventions that address reducing 30-day readmissions such as post-discharge phone calls, RED toolkit, BOOST toolkit, transition coaches, and home visits after discharge. Despite these tools, 30-day readmission rates among the older adult population continue to be a challenging issue.

As we care for our patients in a hospital settings, our goal is to get them better so that they can be discharged. Most of the time recovery continues at home or at another facility. With shorter stays in the hospital setting, the recovery at home requires increased nursing and caregiver interventions. Based on statistics published by the Center for Medicare and Medicaid Services (CMS), the rate for readmission, within the first 30 days of discharge, in 2012, for Medicare FFS (Fee-for-service) beneficiaries, averaged 18.4 percent (Gerhardt et al., 2013). Throughout this paper, readmission refers to a “return hospitalization to an acute hospital following a prior acute admission within

established the clinical problem that heart failure is associated with high morbidity and poor prognosis (Hobbs, et al., 2007). She further added that it decreases patients’ quality of life as it places a heavy burden on them, as well as their families, as well as the huge negative impact on health care resources (Iqbal, et al, 2010), contributing to lost productivity from unplanned hospital admissions. The authors presented the research problem strongly, stating that there is a limited study of the role of specialized heart failure nurses in the multidisciplinary team in managing heart failure patients, thus warranting a further investigation to be conducted. Special nurses, as defined by Glogowska et al, are experienced senior nurses who are involved in providing medical, psychological and emotional support that begins at the initial diagnosis of heart failure and continues onward. They provide transitional care in assisting patients manage their heart failure. The research article focus on the experiences and perceptions of clinicians in managing heart failure patients, and it aims to understand the special role of specialized heart failure nurses in the interdisciplinary team. The authors designed to answer the following questions when conducting this study:

The biggest take-away I have from watching the Improving Transitions of Care videos is that transition of care has been and continues to be a huge ongoing problem with poor communication between the healthcare providers and the patient. As posited by Dr. Eric Coleman in the Module 1 video, we should consider one in five Medicare patients being readmitted within 30 days of discharge from the hospital as unacceptable (Joint Commission Resources [JCR], 2010). According to the video series, there are several projects being implemented to improve the discharge planning process and thus decrease the need for hospital readmission (JCR, 2010). A few of the tools being used such as, the After-Hospital Care Plan, more comprehensive teaching about diagnosis,

A new study released March 16, 2016 by Kaiser Permanente found that heart failure patients had a 19% lower risk of being readmitted to the hospital within 30 days when they were followed up within 7 days of being released from the hospital. The Heart Failure Management program aims to provide early follow-up within one week either by telephone or by office visit if necessary. According to the study, 45 percent of the telephone calls were made by non-physician providers who are qualified to adhere to an outpatient heart failure treatment protocol. Protocols have been established and approved by the participating cardiologists in the community and are evidenced-based driven so that patients will be receiving the best care possible.

As the population of persons age 65 and greater continues to rise so does the number of individuals suffering from heart failure. With an estimated 5.1 million adults with the diagnosis of heart failure it is currently the number reason for hospital admissions for the Medicare eligible population. Readmission within 30 days occurs in approximately 25% of this population, resulting in a significant financial burden to the health care delivery system. There is substantial literature supporting strategies to help reduce the number of readmissions and moreover cost of care. Addressing patient and family needs to provide self-management has proven to reduce readmissions by comprehensive care coordination, supportive home care visits

Patient HH eligibility and/ or connection with care coordination (adding if phone call was made to CMA);

According to the literature, heart failure (HF) is a complex disease that requires intricate management strategies. The demands to reduce the costs associated with heart failure admissions and readmissions are increasing across the health care industry. The purpose of this project is to examine the use of an education protocol for HF patients and its impact on multidisciplinary team members’ perceptions of structured patient education and reducing heart failure admissions and readmissions. There are numerous nursing research studies that describe the implementation of a protocol for patient education, discharge teaching, and the effects on patient outcomes. This literature review summarizes pertinent research related to heart failure management, heart failure education, and relevance of education guidelines in reducing HF readmissions. The following literature has been studied, and the practice evidence has been applied while making the protocol for the heart failure education. Databases searched included CINAHL, Proquest, PubMed, PsycINFO, and Health Source: Medline.

Allen et al. (2014) performed data review of 12 articles (evidence-based studies) to compare readmissions rates, length of stay, and use of transitional care intervention, follow-up. Providers responsible for implementation of transitional care interventions in the studies were also evaluated and in 5 of the studies transitional care was initiated by advanced practice nurses. Eleven of the 12 studies evaluated readmission rate using transitional care versus standard care. Six of these studies showed decrease readmission rates in the intervention group, 3 found no reduction, 1 demonstrated higher rates (thought to be related to VA status of patients) and 1 did not have sufficient information to make comparison. Lengths of stay and quality of life outcomes were

Team-based care is more than a group of diverse clinicians working together to care for patients. It is a paradigm shift that moves from a mindset of “I” to a mindset of “we.” Traditional practice models are often centered on a lone physician who makes all patient care decisions. Specific tasks may be delegated, but the physician maintains all the responsibility. TBC distributes not only tasks but also the responsibility for patient care. It empowers every team member to function to the best of their ability and make their highest contribution to patient care (Ghorob & Bodenheimer, 2015).