Discharge Planning for Readmission Prevention

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Discharge Planning for Readmission Prevention

Introduction

Patient wellbeing is among the primary concerns of healthcare. While during in-hospital treatment, patients are under constant control, and their condition is monitored, after the discharge, the incidence of negative patient outcomes can increase. For example, high morbidity is observed among patients with respiratory conditions, elderly patients in particular. There is evidence that discharge planning can positively influence patient outcomes and reduce the risk of readmission within 30 days (Hall, Chang, & OGrady, 2016). Thus, there is a need for guidelines regarding discharge planning and implementation of this plan into nursing practice. The current change project considers discharge planning as an intervention that can reduce readmission rates and positively influence patient outcomes.

Change Model Overview

One of the popular models that can be applied for change projects in conditions of evidence-based practice is the ACE Star Model. It was developed by Kathleen Stevens and is also called the model of knowledge transformation (White & Dudley-Brown, 2016). ACE Star Model comprises five stages with specific functions, such as knowledge discovery, evidence summary, translation into practice, integration into practice, and evaluation (White & Dudley-Brown, 2016). This model should be used by nurses to facilitate change in evidence-based practice due to the fact that it comprises the translation of knowledge obtained as a result of discovery into nursing practice and its following evaluation that allows us to define drawbacks and benefits and make necessary alterations to make the model more effective.

Define the Scope of the EBP

The scope of the evidence-based practice in this project is the fact that discharge planning provides a challenge for healthcare professionals of different countries, including both the developed and developing ones. The latter experience the majority of the adverse effects, chiefly in the area of patient outcomes, with the increased mortality rate being the most apparent example. Nevertheless, the financial restrictions make it an equally pressing concern for the former. There are no exact statistics about readmission rates of patient mortality after discharge related to diverse respiratory conditions. Still, there is evidence that discharge planning reduces readmission of high-risk patients (Bowles, Hanlon, Holland, Potashnik, & Topaz, 2014). As for the impact on healthcare on a broader scale, the implementation of discharge planning can, first of all, improve the patient outcomes after discharge, and, secondly, save costs due to readmission shortening.

Stakeholders

There is no need for a big team for this project. The team will include a leader, a general physician, a charge nurse, and three visiting nurses.

Determine Responsibility of Team Members

These team members are important for the project because they provide their implementation and are responsible for work with patients. Thus, a project leader will control the implementation process. A general physician will evaluate the condition of patients before discharge and after a 30-days period. A charge nurse will administer the work of other nurses involved in the project. Finally, visiting nurses are expected to visit patients after discharge and provide control over the developed discharge plan.

Evidence

Evidence for the change project was found in the result of a literature search. The selected investigations provide evidence for the effectiveness of the discharge planning and include implications for the evidence-based change project.

Summarize the Evidence

The major study used for evidence in this project is research by Hall et al. (2016) that evaluates the effectiveness of a specific type of discharge plan assigned individually in the process of repeated hospitalization associated with chronic lung diseases. The efficiency of this intervention is determined through a comparison with a control group. The research addresses the question of improved patient outcomes as a result of an individually developed discharge plan. The possible improvement is expected to be a result of improved communication between patients and healthcare providers, better information on the inpatient and outpatient services provided in the area, better coordination of care after the discharge, and promotion of a healthy lifestyle. The researchers suggest an intervention that is grounded on the involvement of a caseworker assigned to a patient at admission. The task of this person is to adjust the standard plan in accordance with the patients individual needs. Moreover, it is expected to involve both the patients and their families in the treatment process through support, motivation, and behavior risk modification.

Another evidence is found in the research by Bowles et al. (2014). This quasi-experimental study discovered the influence of discharge planning decision support on time to readmission. The sample included older adult patients who are considered high-risk patients. The study proved that the relative rate of readmission for high-risk patients decreased by 26% due to individual discharge planning (Bowles et al., 2014). Finally, Abad-Copra et al. (2013), in their research, evaluated the efficiency of hospital discharge planning for patients with chronic obstructive pulmonary disease (COPD). Since COPD is a widely-spread morbidity and mortality cause, the need for interventions to reduce risks was needed. The research revealed the fact that discharge planning is efficient for patients with COPD because it positively influences the quality of life after the discharge and improves the knowledge of patients about the disease that also has a positive impact.

Develop Recommendations for Change Based on Evidence

Based on the presented evidence, the implementation of discharge planning as a change project can be recommended. The recommendations are as follows:

develop guidelines for discharge planning for older adult patients with respiratory conditions;
provide nurse education to enable them to work with discharge planning;
develop patient education interventions to explain them the significance of following the plan after the discharge;
apply discharge planning for older adult patients with respiratory conditions.

Translation

Action Plan

The action plan for the project will include the following steps.

Select the team
Educate the team members about the project peculiarities
Develop interventions for the project implementation
Select the sample among the patients
Implement the project
Assess patient outcomes
Evaluate the effectiveness of discharge planning
Report the results.

The timeline for this project is two months. Two weeks are necessary for the preparatory stage, 30 days for the change project implementation, and two to three weeks are needed for the evaluation and reporting results.

Process, Outcomes Evaluation and Reporting

The desired outcomes include reduction of readmission rates among the patients who received discharge plans. It will be measured by comparing readmission rates before and after project implementation. The results will pe presented to the major stakeholders in a form of a report.

Identify Next Steps

This plan can be implemented on a larger scale because it is applicable to any other unit and any group of patients. To ensure the permanent implementation of the change project, it is necessary to provide nurse education and inform the staff about the effectiveness of discharge planning.

Disseminate Findings

The findings revealed during the project implementation can be disseminated both internally and externally. For example, they can be shared in a form of a presentation for colleagues or published in journals or some online resources.

Conclusion

On the whole, the change project aimed at the implementation of discharge planning is expected to be effective. It comprises all the aspects of the ACE Star change model, such as the discovery of knowledge, evidence proving the efficiency of discharge planning, ideas for translating the project into practice, an integration plan, and evaluation stage. The maintenance of the change plan can be provided through its inclusion as a regular practice within a healthcare facility.

References

Abad-Corpa, E., Royo-Morales, T., Iniesta-Sánchez, J., Carrillo-Alcaraz, A., Rodríguez-Mondejar, J., Saez-Soto, Á., & Vivo-Molina, M. (2013). Evaluation of the effectiveness of hospital discharge planning and follow-up in the primary care of patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing, 22(5-6), 669-680.

Bowles, K., Hanlon, A., Holland, D., Potashnik, S., & Topaz, M. (2014). Impact of discharge planning decision support on time to readmission among older adult medical patients. Professional Case Management, 19(1), 29-38.

Hall, K. K., Chang, A. B., & OGrady, K. F. (2016). Discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness. The Cochrane Library, 8. Web.

White, K.M., & Dudley-Brown, S. (2016). Translation of evidence into nursing and health care practice (2nd ed.). New York, NY: Springer Publishing Company.

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