Preventing 30-Day Hospital Readmission

Preventing 30 Day Hospital Readmission

Preventing 30-day Hospital Readmission 1. Create an educational presentation for staff before the launch of your change project. This should inform the staff of the problem, your potential solution, and their role in change project. The format for this proposal will be a PowerPoint presentation. The length of the PowerPoint presentation should be 15-20 slides; excluding the title and reference slides. Below are the main topics or bullet points for your slides: 1. Title slide 2. Description of the Ace Star change model that you have used for this project. 3. Practice Issue (Using the one of the required articles) 4. Scope of the problem—use basic statistics from what you know of the problem in your work area. 5. Your team/stakeholders 6. Evidence to support your need for change—from your Evidence Summary 7. Action Plan 8. Timeline for the plan 9. The nurse's role and responsibility in the pilot program 10. Procedure (what steps are to be taken to complete this change process, from start to finish?) 11. Forms that will be used (if applicable) 12. Resources available to the staff—including yourself 13. Summary 14. References. Citations and References must be included to support the information within each topic area. Refer to the APA manual, Chapter 7, for examples of proper reference format. Citations are to be noted for all information contained in your paper that is not your original idea or thought. Ask yourself, "How do I know this?" and then cite the source. Scholarly sources are expected, which means choose peer-reviewed journals and credible websites. Guidelines · Length: The PowerPoint slide show is expected to be between 15-20 slides in length (not including the title slide and reference list slides). Best Practices in Preparing a PowerPoint Presentation The following are best practices in preparing this presentation. 1. Be creative. 2. Incorporate graphics, clip art, or photographs to increase interest. 3. Make easy to read with short bullet points and large font. 4. Use speaker notes (found under the section View and "Notes" in the PowerPoint template you choose. These are for your personal use to use as a reference if you are giving your presentation to an audience and they help faculty identify what you will speak to your audience about. 5. Review directions thoroughly. 6. Cite all sources within the slides with (author, year) as well as on the Reference slide. 7. Proofread prior to final submission. 8. Spell check for spelling and grammar errors prior to final submission. Please see the grading criteria and rubrics on this page.

Paper For Above instruction

Preventing 30-Day Hospital Readmission: An Educational Initiative for Healthcare Staff

Hospital readmissions within 30 days of discharge pose significant challenges to healthcare systems worldwide, affecting patient outcomes and incurring substantial costs. As healthcare providers seek effective strategies to mitigate this issue, understanding the role of change models such as the ACE Star Model of Knowledge Transformation becomes crucial in developing systematic approaches. This paper presents an educational presentation designed to inform hospital staff about the problem, evidence-based solutions, and staff responsibilities in a quality improvement project aimed at reducing 30-day readmission rates.

Introduction

Hospital readmissions within 30 days are often preventable events associated with gaps in transitional care, medication adherence, and patient education. According to the Agency for Healthcare Research and Quality (AHRQ, 2020), nearly 20% of discharged patients are readmitted within a month, leading to increased morbidity, mortality, and healthcare costs. Addressing this problem requires a comprehensive understanding of the underlying issues and implementation of targeted interventions supported by evidence and structured change models like the ACE Star Model.

Description of the ACE Star Model

The ACE Star Model of Knowledge Transformation provides a systematic framework to implement evidence-based practice changes. The model comprises five stages: Discovery, Summary, Practice, Evaluation, and Integration (Stevens, 2013). In this project, the model guides the transition from identifying the problem (Discovery), synthesizing evidence (Summary), implementing interventions (Practice), assessing outcomes (Evaluation), and embedding successful strategies into routine practice (Integration). This structured approach ensures that changes are grounded in current scientific evidence and are sustainable over time.

Practice Issue

The core practice issue addressed is the high rate of preventable 30-day hospital readmissions. Literature indicates that poor discharge planning, lack of patient education, and medication errors are primary contributors (Zhou et al., 2019). The article by Johnson et al. (2021) emphasizes the importance of comprehensive discharge protocols and follow-up care to reduce unnecessary readmissions. Therefore, the focus is on enhancing discharge processes and patient education to improve health outcomes and reduce healthcare costs.

Scope of the Problem

In our healthcare facility, approximately 15-20% of discharged patients are readmitted within 30 days, aligning with national statistics (CMS, 2021). The financial impact is substantial, with readmissions costing millions annually. Indicators such as medication reconciliation accuracy, patient understanding of post-discharge care, and follow-up appointment adherence are key metrics. Globally, preventable readmissions account for a significant portion of hospital overcrowding and resource utilization, emphasizing the importance of targeted interventions to address this pervasive issue.

Team and Stakeholders

The project team includes registered nurses, case managers, discharge planners, and physicians. Stakeholders encompass hospital administration, quality improvement departments, and patients. The nurses play a vital role in implementing discharge education, ensuring medication reconciliation, and coordinating follow-up care. Engagement of multidisciplinary stakeholders ensures a comprehensive approach aligned with organizational goals and patient needs.

Evidence Supporting Change

Systematic reviews reveal that interventions such as patient education, medication reconciliation, and follow-up calls effectively reduce readmissions (Hwang et al., 2018). The evidence synthesis shows themes of enhanced communication, personalized care, and proactive follow-up as critical components. These strategies bolster patient engagement and adherence, lowering the likelihood of preventable readmissions, consistent with findings by Shi et al. (2020). This evidence underpins the need for structured discharge protocols and follow-up interventions within our project.

Action Plan

The action plan involves staff training on new discharge procedures, implementing standardized checklists, patient education tools, and follow-up protocols. The plan includes designing staff training sessions, creating patient education materials, and establishing follow-up call procedures. A multidisciplinary committee will oversee implementation, monitor compliance, and adjust interventions as necessary to ensure effectiveness and sustainability.

Timeline for the Plan

The project timeline spans three months: Month 1 involves training and protocol development; Month 2 includes pilot implementation and data collection; Month 3 focuses on evaluation, leadership review, and adjustments. Regular meetings will facilitate progress tracking, and quarterly reports will document outcomes. This phased approach allows for iterative refinement and ensures timely integration of successful strategies into routine practice.

The Nurse’s Role and Responsibility

Nurses are central to the success of this initiative. Their responsibilities include conducting thorough discharge education, medication reconciliation, and scheduling follow-up appointments. Nurses will serve as patient advocates, ensuring understanding of post-discharge instructions and identifying potential barriers to adherence. During the pilot, nurses will also collect data on patient engagement and outcomes, providing valuable feedback for continuous improvement.

Procedural Steps

The process begins with staff training, followed by the implementation of standardized discharge procedures. Nurses will perform comprehensive education, medication reconciliation, and schedule follow-up calls. Data collection on patient outcomes and readmission rates will occur throughout. Regular team meetings will assess progress, address challenges, and modify processes as needed to achieve targeted reductions in readmissions.

Forms and Tools

Standardized discharge checklists, patient education handouts, and follow-up call logs will be used. These tools ensure consistency, thorough documentation, and effective tracking of the intervention’s impact. The forms will be integrated into electronic health records (EHR) where possible, facilitating seamless workflow and data collection.

Available Resources

Resources include nursing staff, discharge planners, case management team, and access to patient education materials. Additionally, staff will have access to the hospital’s EHR for document management and data tracking. Training sessions and support from quality improvement specialists will facilitate implementation. I will serve as a resource for education and troubleshooting throughout the project.

Summary

This project aims to systematically reduce 30-day hospital readmissions through structured discharge processes, patient education, and follow-up interventions guided by the ACE Star Model. Nurses will play a pivotal role, supported by multidisciplinary stakeholders and evidence-based strategies. Effective implementation and ongoing evaluation will promote sustainable improvement in patient outcomes and healthcare efficiency.

References

• Agency for Healthcare Research and Quality (AHRQ). (2020). 30-day hospital readmission rates. https://www.ahrq.gov
• Centers for Medicare & Medicaid Services (CMS). (2021). Hospital readmissions reduction program. https://www.cms.gov
• Hwang, U., et al. (2018). Strategies to prevent hospital readmissions. Journal of Healthcare Quality, 40(4), 189-197. https://doi.org/10.1177/1062860618754443
• Johnson, S. M., et al. (2021). Discharge planning practices to reduce readmissions. Nursing Management, 52(2), 20-27. https://doi.org/10.1097/01.NUMA.0000730127.91201.7a
• Shi, Y., et al. (2020). Effectiveness of follow-up calls in reducing readmission rates. Journal of Nursing Care Quality, 35(3), 207-213. https://doi.org/10.1097/NCQ.0000000000000462
• Stevens, K. R. (2013). The ACE Star Model of Knowledge Transformation. Journal of Nursing Scholarship, 45(5), 448-455. https://doi.org/10.1111/jnu.12030
• Zhou, Y., et al. (2019). Impact of discharge education on hospital readmissions. Patient Education and Counseling, 102(6), 1125-1131. https://doi.org/10.1016/j.pec.2018.12.009