Healthcare Research Proposal on Discharge Planning and Its Effect on Readmission

Readmission has greatly been a problem affecting many health-related establishments. More hospitals are affected financially through the readmission process together with patients paying more for treatment at the establishments. Coming up with a proper plan to deal with the issue is quite important, and that is why discharge planning will be dealt with in this paper as a solution to the problem of readmission.

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Change Model Overview

The AC Star Model of EBP is helpful in comprehending the characteristics, nature, and cycles of information that are used in different areas of evidenced-based practice (EBP). The model is quite important to nurses in their daily tasks as they can make use of the different inbuilt concepts that are old and new and that help in guiding the provision of care. The model deals with knowledge transformation that provides an overview of the different care approaches and the relationships existing between them that can thus guide nurses in carrying out their duties. It further encompasses the various elements of EBP.

Define the Scope of the EBP

The practice issue is the issue of readmission of patients with PNA and the effect of beginning education in the reduction of readmission within thirty days particular by twenty percent. Readmission is a great problem particular when it happens in a short time as it affects the quality of care provision in hospitals and renders them infective in meeting the health needs of the general population. The practice issue at hand is the readmission into hospitals of already treated patients. Furthermore, readmission poses problems to hospitals through financial loses while further burdening the patients with more costs going towards treatment in the respective hospitals. The problem is thus the readmission of people suffering PNA can lead to major outbreaks and expensive handling of the condition particularly due to resistance to the available medications, which will call for more funds to look for new drugs making it quite costly.

Stakeholders

The various members of the team will be the family member or relatives to the patients, doctors, admission staff, resident nurses, interns, patient representative, registered nurses, enrolled nurses, and charge nurses.

You will be the leader of the team since this is your project. Whom will you also include in your team? Make sure you choose relevant stakeholders. You should have no more than eight members. Do not list your team members by name but instead by position (pharmacists, charge nurse, etc.).

Determine Responsibility of Team Members

The various stakeholders will have different roles in associated with their duties. The charge nurse will help in providing more information on the patients and the readmission particular their treatment history. The enrolled and registered nurses will further give more information on the recovery of the patients. The family and relatives of the patients of the patients will further provide information regarding the readmission of the patients and how they dealt with the recovery process. The patient representative will further provide information on the complaints made by the patients specifically their grievances regarding care provision at the establishment about their readmission. The admission staff will further provide information on the admissions and readmission of patients with various comparisons together with associating with how care was provided.

Why are the members chosen important to your project? What are their roles?

Evidence

The evidence, in this case, is quite important when dealing with the readmission. The evidence, in summary, was further associated with the various admission of the patients in the hospitals. The care process, in this case, was found out to be ineffective in the cases associated with the readmitted patients. Not all of them were readmitted, and therefore there was an issue that needed to be solved. Most nurses and doctors who had helped in care provision and treatment of patients were able to state that the patients had started recuperating at the time they left the hospital. The readmission further showed the flaw in the admission and readmission processes where the patient was only treated and not given any information regarding on how they were to continue their recovery process at home.

Recommendations for Change Based on Evidence

It is recommended that on the issue involving the readmission discharge planning is required. Discharge education, directing, and guiding the patients on how to handle their recovery process. The recovery processes will require that the stay and the discharge of the patients at the hospitals be carried out through providing information to the patients specifically on their discharge and recovery process. Through the care process form, the other successful patient discharges there is need to follow up on discharge planning. The discharge planning is quite an important step that will help nurses in providing the information (Goncalves-Bradley et al., 2016)

Action Plan

In developing the pilot study, I will further come up with discharge planning. The various steps in taking to deal with discharge planning will involve discharge education. The action plan will thus involve various elements regarding discharge planning. It will include assessment of caregivers in discharge planning, providing a plan on visiting patients in their home areas to assess the adequacy that will either help them recover or worsen in their treated conditions, determine when discharge planning will be applied to the patient particular when they are in or out of hospital and provide patients with education information that will help them recover quickly. Furthermore, the patients will be monitored even as they are discharged from the hospital. The plan will thus involve the following up of patients in their home environment together with providing information to them on how to deal with their condition to prevent readmission into the hospital. The above steps will be implemented in three months as this is the period, which most patients are expected to either recover or be readmitted. The report on the progress of the patients will further be taken into consideration through the assessment reports carried out weekly on the patients. The reports will be consolidated to come up with the main report on the progress of the patient. Furthermore, the effectiveness of the process of preventing readmission through discharge planning will be monitored and evaluated on a weekly basis through the checking on the condition of the patient.

The process, Outcomes Evaluation, and Reporting

The process, in this case, will involve the provision of information to the patient and guiding them on how to useful recover together with guiding their families in the process. The desired outcomes are to prevent any readmission from taking place. Since hospitals are areas of providing care the ineffectiveness that arises through admission may soil the reputation of some hospitals, which may be costly to them as they may be fined in the process. Furthermore, less or no patient readmission will ensure that costs by both parties are lessened. Therefore through the evidence-based approach where the patient is taken through the discharge planning process using an effective approach of monitoring them and ensuring that their environment is conducive for their recovery, readmission will be lessened greatly hence achieving the outcome of successful recuperation among the patients released.

The outcomes will be measured on a weekly basis while monitoring the condition of the patients involved. Readmission will further be monitored as the process continues while the use of evidence-based methods together with discharge planning are put to use both at the hospital and in the home environment of the respective patients.

The results will be presented to the key stakeholders through forums and presentations that are both printed and digital. The nurse practitioners together with other staff will be provided the information through emailing in the hospital. The relatives of the patients will receive the information regarding the project on a weekly basis even as the patient is monitored. Quality issues involved in the care process will further be handled through the information gained as the health practitioners perform their duty.

Identify Next Steps

Implementing discharge planning as an intervention on a larger scale will require associating with policymakers in the health sector among other authorities. Discharge planning, in this case, can be implemented in hospitals as a requirement through various regulations and guidelines that will help prevent readmission in such hospitals. The various steps to implement in other facilities will also follow through meeting with the various heads of the different establishments and providing them with the action plan that is tailored to their different institutions. In ensuring, that the implementation becomes permanent, there will thus be the need to consider the help of legislative bodies both at the local and federal level. Making legislation towards the same will ensure that all hospitals carry out the discharge planning process in their hospitals.

Disseminate Findings

The finding will be communicated to the organization with a forum that will use the presentation of the findings in using the discharge planning approach. The various healthcare stakeholder forums will be used to disseminate the discharge planning process to other establishments. The information will also be shared on the internet through health-related websites to reach as many establishments as possible. Various forums will further be used where many establishments come together and hence help in disseminating the information.

Conclusion

Using the ACE star model has greatly helped in defining the various problems associated with readmission to the facility. Furthermore, discharge planning has been found to be effective in dealing with the issue of readmission and lessening it largely. More patients and establishments suffer due to the number of readmissions. It is therefore important to note on the importance of discharge planning where the patient is not only treated but also guided through information given to speed the recovery and deal with various obstacles that may worsen the condition in question. Thus noting on the cycles affecting readmission and the various inept processes that may be in play will help greatly in using evidence-based approaches that provide a wealth of information on dealing with patient care by staff to ensure a quick recovery.

References

Goncalves-Bradley, D. C., Lannin, N. A., Clemson, L. M., Cameron, I.D., & Shepperd, S. (2016). Discharge planning from the hospital. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD000313. doi:10.1002/14651858.CD000313.pub5.