Patient Care Delivery

Sample Answer

Background of the Issue

The fastest-growing cardiovascular ailment in the world, heart disease poses significant clinical and financial difficulties for the healthcare system. According to Saxena et al. (2022), each year, an estimated $108 billion, or 2% of the global healthcare budget, is spent on heart disease.

This statistic mostly pertains to high hospitalization rates, of which half are believed to be possibly preventable and is projected to climb over the next two decades. In addition, admission rates for those with heart disease are rising, and there are differences in sex, socioeconomic level, and ethnicity.

A recent past hospitalization is one of the best indicators that a patient with heart disease will be admitted to the hospital. Almost 22% of patients with heart disease who are hospitalized have potentially unnecessary readmissions within 30 days of leaving, which are linked to high expenses and a poor prognosis (Puyana et al., 2022).

As a result, governments throughout the world have long set a goal of lowering 30-day readmissions to cut costs and enhance healthcare quality.

PICOT-D Question

Patients are at higher risk in the days right after being released from the hospital. The best transitions between the hospital and ambulatory sectors are essential for enhancing health and lowering readmissions because of the stresses, deconditioning, and residual consequences of disease that can occur during hospitalization (Matsukawa et al., 2021).

Early physician follow-up became a standard of treatment after research showed that patients with CHF who had early doctor follow-up after discharge had 30-day readmission rates that were lower (Macchio et al., 2020).

Clinicians can evaluate the patient’s status, comorbidities, medicines, and treatments during an early follow-up. They can also explain discharge instructions and create a plan if symptoms continue.

SWOT Analysis

Strengths

Internal and external aspects were considered using the SWOT analysis to determine whether this project could be executed in a long-term care institution. The project’s interests and support from management were one of its internal strengths (Saxena et al., 2022).

The vast patient population that would profit from this initiative, which employs evidence-based methodologies to choose and track patient follow-up therapies, was another internal strength. In contrast to needing to go to a metro facility for the same services, this critical access hospital is situated in a rural area where patients may obtain assistance controlling their congestive heart failure closer to home.

Weaknesses

Even with close follow-up and monitoring, patients’ noncompliance was the first internal weakness that the SWOT analysis identified. Concern was voiced regarding patients’ refusal to take part in post-discharge education when speaking with the manager of the neighborhood health department.

After being discharged, patients would need to visit their primary care physician more quickly, and some patients could need daily phone calls to check on their weights, medication compliance, and nutritional intake. The inability to contact the patient after hospital release prevented close monitoring of self-management activities, which was the second internal vulnerability (Puyana et al., 2022).

The doctoral student, the team lead, was unable to effectively express patient requirements and concerns to the primary care practitioner as a result of the provider’s absence, which was the third vulnerability found. Because the team lead could communicate openly with the main care physician, the project was conducted in an environment where primary care physicians were present.

Opportunities

The SWOT analysis indicated increasing patient participation in the program and proper patient compliance as an external opportunity. To select patients who might benefit from the program, the team leader would have to collaborate closely with social services and the hospitalist group (Lee et al., 2020).

Also, by making the program available to patients with congestive heart failure, fewer hospital readmissions where cardiovascular disease is the admitting diagnosis would occur (Ko et al., 2020). Most significantly, there would be a decrease in patient fatalities as a result of complications from congestive heart failure.

Threats

An external threat was discovered to be the inability to get in touch with the patient after discharge and/or inadequate follow-up phone conversations with patients when the requirement for necessary medical treatment is not detected. The study wouldn’t be effective and wouldn’t lower patient mortality and hospital readmissions if self-management measures weren’t appropriately monitored (Nair et al., 2020).

Another external hazard highlighted is a lack of resources and time for the project to be performed correctly. Another risk to the project’s success is that if participation in the program is limited, there may not be enough data to support the requirement to hire someone for the team lead job and execute the program’s duties.

Proposed Solution

Also, it has been shown to reduce the 30-day readmission risk to schedule timely follow-up consultations with a cardiologist or primary care provider within seven days of release following HF hospitalization (Macchio et al., 2020). Patient education is part of the readmissions prevention strategy.

Education must be a part of both the first hospital stays and later visits. For the foreseeable future, every interaction with the patient should include an assessment and targeted instruction. There should be specific inquiries about the patient’s diet, medication compliance, and water consumption (Matsukawa et al., 2021).

Such targeted communication will aid in filling in knowledge gaps and reinforcing previously covered material. Research has revealed that the key to lowering HF readmissions is teaching and reinforcement. Suggested Ways That the Proposed Solution Meets the Needs of the Population.

Also, it has been shown that lowering the nurse-to-patient ratio can reduce readmission rates. Because having enough nursing personnel to educate the patient was crucial to our study, this may have indirectly helped us achieve our aim. For patients with HF, optimizing medical treatment is crucial for better outcomes and less hospitalization (Tang et al., 2022).

Patients with HF with a low ejection fraction have been proven to benefit from and see a reduction in readmissions while using beta-blockers, ACEIs or ARBs, and spironolactone. Also, it has been demonstrated that spironolactone lowers hospitalizations in HF patients with intact ejection fraction.

Those who were discharged on torsemide were less likely to require HF readmission than those who were on furosemide. As a result, ensuring that patients are on the right pharmaceutical regimen after each hospital admission can aid in reducing the likelihood of further hospital stays.

According to the results, early consultation with a physician in the ED is linked to fewer readmitted days, re-hospitalizations, and medical expenses for individuals who return to the ED after being discharged (Ogunwole et al., 2019). As compared to previously published results, heart failure symptoms improved while mortality remained constant.

Study results indicate that early consultation with a physician familiar with each patient may significantly lower re-hospitalization and healthcare costs for patients who come back to the ED despite exacerbated education and follow-up without adversely affecting mortality or heart failure symptoms (Ko et al., 2020).

Centers with too many 30-day readmissions are penalized by the Centers for Medicare & Medicaid Services (CMS). Penalties are applied disproportionately to facilities that provide treatment for underserved patients because target rates are not adjusted for social inequities (C et al., 2021).

Reduction efforts have met with various degrees of effectiveness, particularly in metropolitan patients from low socioeconomic backgrounds. These people frequently overuse the emergency department (ED) for their care, consuming disproportionately more healthcare resources than more wealthy patients. This results in fragmented care and higher healthcare expenses. As a result, lowering the readmission rates will aid in cutting down on such unnecessary expenses.

Proposed Change Process for Patient Care Delivery
After three days of being released, patients will receive a call from a highly trained nurse who will use a standardized questionnaire to assess their condition (Tang et al., 2022). A cardiovascular nurse practitioner (NP), social worker, or pharmacist will get in touch with patients who give worrying answers, and modifications will be made to their prescription schedule as needed.

Within seven to fourteen days following release, every patient will obtain an appointment with their cardiologist or cardiovascular nurse practitioner as well as an appointment with their primary care physician. Each appointment will include an evaluation of the patient’s symptoms, a physical exam, a discussion of any new complaints, reinforcement of education, and any necessary adjustments to medication.

Expected Outcomes

The main anticipated result is a reduction of at least 25% in all-cause unplanned re-hospitalization within 30 days after release (Ogunwole et al., 2019). The project will not consider planned re-hospitalizations (such as elective operations and chemotherapy treatments).

Improved patient outcomes, decreased morbidity and death rates, decreased ED re-visits, decreased overall re-hospitalization days, and decreased 30-day healthcare costs at our facility are secondary intended outcomes(Puyana et al., 2022).

Implications of the Proposed Solutions Are Realistic and Aligned With Health Care Planning. Because it has been demonstrated to decrease readmissions and improve clinical outcomes, the transition of treatment from the hospital to the home is a growing area of emphasis for quality-of-care improvement (Lee et al., 2020).

Several studies have demonstrated that cardiologist follow-up of patients suffering from heart failure following ED discharge is related to improved clinical outcomes in the ambulatory care context (C et al., 2021). The management of patients after discharge may have a substantial influence on healthcare delivery given the enormous number of patients that visit the ED for the examination of chest discomfort. Implications of the Proposed Solutions That Are Realistic and Aligned With

Current and Future Health Care Financing

The total reduction in expenditure on healthcare services is another significant advantage of lowering readmissions. The Hospital Readmission Reduction Program (HRRP), a value-based buying initiative that tries to reduce patient readmission via greater care coordination and communication, is expected to save Medicare $521 million, according to the CMS (Nair et al., 2020).

Because a percentage of Medicare payments may be withheld under the Hospital Value-Based Purchasing Program if a hospital doesn’t fulfill requirements for the quality of treatment, including the patient experience, patient satisfaction rankings are very important. This has inspired many doctors and other healthcare professionals to put the quality of treatment before the number of patients treated.

Avoiding financial fines is also another significant advantage of decreasing hospital readmissions. Medicare reduced payments to 2,499 hospitals, or 47% of all facilities, in 2021 as a result of high readmission rates, with estimated fines totaling $521 million (Puyana et al., 2022). By putting their attention on patient care and care coordination, hospitals may stay out of trouble and use their money to improve their facilities, staffing, and technology.

Conclusion

There is a lot of heterogeneity in the hospital-level rates of immediate outpatient follow-up following release among patients who are admitted for cardiopulmonary problems. Patients who leave hospitals with higher early follow-up rates are less likely to be readmitted within 30 days. While patients move between sites, transitional care is intended to maintain coordination and continuity in their medical treatment.

Communication between the sending and receiving doctors, preparing the patient and caregiver for what to anticipate at the subsequent site of care, medication reconciliation, follow-up plans for unfinished testing, and conversations about keeping an eye out for indicators of deteriorating diseases are all crucial components of transitional care.

References

• C, L., H, C., S, R., I, S., F, Z., L, D. M., Bernhardt, K, R., R, L., & K, K. (2021). Trends in 30-day readmissions following hospitalization for heart failure by sex, socioeconomic status, and ethnicity. EClinicalMedicine, 38, 101008. https //doi.org/10.1016/j.eclinm.2021.101008
  
• Ko, D. T., Khera, R., Lau, G., Qiu, F., Wang, Y., Austin, P. C., Koh, M., Lin, Z., Lee, D. S., Wijeysundera, H. C., & Krumholz, H. M. (2020). Readmission and Mortality After Hospitalization for Myocardial Infarction and Heart Failure. Journal of the American College of Cardiology, 75(7), 736–746. https //doi.org/10.1016/j.jacc.2019.12.026
  
• Lee, K. K., Thomas, R. C., Tan, T. C., Leong, T. K., Steimle, A., & Go, A. S. (2020). The Heart Failure Readmission Intervention by Variable Early Follow-up (THRIVE) Study. Circulation Cardiovascular Quality and Outcomes, 13(10). https //doi.org/10.1161/circoutcomes.120.006553
  
• Macchio, P., Farrell, L., Kumar, V., Illyas, W., Barnes, M., Patel, H., Silverman, A. L., Hong Le, T., Siddique, H., Raminfard, A., Tofano, M., Sokol, J., Haggerty, G., Kaell, A., Rabbani, S., & Faro, J. (2020). 30-day readmission prevention program in heart failure patients (RAP-HF) in a community hospital creating a task force to improve performance in achieving CMS target goals. Journal of Community Hospital Internal Medicine Perspectives, 10(5), 413–418. https //doi.org/10.1080/20009666.2020.1800910
  
• Matsukawa, R., Masuda, S., Matsuura, H., Nakashima, H., Ikuta, H., Okabe, K., Okahara, A., Kawai, S., Tokutome, M., Tobushi, T., & Mukai, Y. (2021). Early follow‐up at outpatient care after discharge improves long‐term heart failure readmission rate and prognosis. ESC Heart Failure. https //doi.org/10.1002/ehf2.13391
  
• Nair, R., Lak, H., Hasan, S., Gunasekaran, D., Babar, A., & Gopalakrishna, K. V. (2020). Reducing All-cause 30-day Hospital Readmissions for Patients Presenting with Acute Heart Failure Exacerbations A Quality Improvement Initiative. Cureus, 12(3). https //doi.org/10.7759/cureus.7420
  
• Ogunwole, S. M., Phillips, J., Gossett, A., & Downs, J. R. (2019). Putting veterans with heart failure FIRST improves follow-up and reduces readmissions. BMJ Open Quality, 8(1), e000386. https //doi.org/10.1136/bmjoq-2018-000386
  
• Puyana, J. S., Hickey, G., Keil, S., Johnson, A., Thoma, F., Mulukutla, S., & Rhinehart, Z. (2022). Timing Is Everything Outpatient Follow-Up Between One And Two Weeks Post-Admission For Heart Failure Is Associated With The Lowest Rate Of Readmission Before 30 Days. Journal of Cardiac Failure, 28(5, Supplement), S120. https //doi.org/10.1016/j.cardfail.2022.03.308
  
• Saxena, F. E., Bierman, A. S., Glazier, R. H., Wang, X., Guan, J., Lee, D. S., & Stukel, T. A. (2022). Association of Early Physician Follow-up With Readmission Among Patients Hospitalized for Acute Myocardial Infarction, Congestive Heart Failure, or Chronic Obstructive Pulmonary Disease. JAMA Network Open, 5(7), e2222056–e2222056. https //doi.org/10.1001/jamanetworkopen.2022.22056
  
• Tang, M., Holmgren, A. J., McElrath, E. E., Bhatt, A. S., Varshney, A. S., Lee, S. G., Vaduganathan, M., Adler, D. S., & Huckman, R. S. (2022). Investigating the Association Between Telemedicine Use and Timely Follow-Up Care After Acute Cardiovascular Hospital Encounters. JACC Advances, 1(5), 100156. https //doi.org/10.1016/j.jacadv.2022.100156