Reducing Hospital Readmissions

Overall, hospital readmission within a short time period, following discharge, is as common as a costly phenomenon in health care delivery, especially to the population with chronic illnesses such as diabetes Mellitus. For diabetic patients, poor follow-up plan contributes to further complication of the patients' condition citing the prevalence of non-adherence to diabetic regime concerning medication administration, diet control, and checking of blood sugar level.  Nevertheless, even telephonic follow-ups stand out as the best nursing focused plan of reducing hospital readmissions, but lack of knowledge (proper health education), access to resources, and support are key contributors to the high percentage of 30-day readmission. Various studies indicate the presence of proper knowledge, easy access to resources such as drugs, and support has seen tremendous success in patients' recovery after discharge. It is further notable that these approaches are effective follow-up plans capable of decreasing the rate of readmissions for those suffering from chronic diseases, especially diabetes mellitus. Therefore, with the aid of change model overview, this paper has focused on investigating how knowledge, access to resources and support would help hospitals reduce the already high percentages of 30-day readmission rates of patients with diabetes mellitus due to non-compliance with diabetes management, of which telephone follow-ups is an unexceptional resource.

Change Model Overview

The ACE star model is identified for its use in various knowledge transformation stages to aid in the reduction of the volume of scientific literature as well as to provide different knowledge forms that are worth incorporating in care along with decision making. Knowledge, as presented in this model is transformed into practice. The ACE Star model is of the essence when nurses want to implement change because it places their previous scientific work regarding the change needed within the context of EBP (Stevens, 2013). The model is more like an organizer helping nurses organize and apply EBP and assist in its flow.

Define the Scope of the EBP

The issues identified in this study is the adverse lack of knowledge (proper healthcare education), access to support, and resources resulting to the problem of a high percentage of 30-day preventable readmission citing non-compliance with the diabetes management. The lack of knowledge, support, and resources indicates the need for ancillary practitioners to prove post-discharge services to the diabetes patients (Harrison, Hara, Pope, Young, and Rula, 2013). Perhaps, it is the health department which led to such issues because the healthcare practitioners do not effectively educate, provide the necessary support and resources to the patients, including telephone follow-ups after discharge.

Medicare allocated reduced payments to Charlotte area hospitals because the federal program decided to penalize this hospital for readmitting many patients within 30 days for additional treatment after their last stay in the hospital. Based on information from the Charlotte area hospitals, 18% of its Medicare patients discharged were later readmitted within their 30 days of discharge. Such readmissions for additional treatment have made many hospitals to account for extra expenditures of 15 billion as outlined in the report presented by the Medicare Payment Advisory Commission (MPAC). There are those local officials of Carolinas health Care who provided spending estimates. For instance, through estimates, it was notable that in 2013 and 2014 Carol Mont hospital had to part away with 111,500 dollars and 99,000 dollars respectively as fines, but since then it has not paid any other penalties.

Stakeholders

Carrying out this research project require suitable team members such as nurses along with clinical educators, nurse managers, and patients together with their families.

Determine Responsibility of Team Members

Every chosen team member for this research project has a critical role to play in its success. Finding existing research studies can be the duty of the nurse manager along with the provision of guidelines suitable as well as help with the initiation of new procedure and policy. As for the other nurses, they are required to handle interventions so that the outcomes can be useful. Any changes or plans during the research are to be reported to the head administrator. Also, the head administrator must ensure that the hospital nursing is performing as well as keep control of hospital cost. On the other hand, the patients and families help with the identification of the research's validity, and that is why their role is critical.

Evidence

Cases of patients with diabetes mellitus readmission have been noticed due to complications from mismanagement and non-compliance of regimen among the old adult populations. Studies have indicated that a lot of readmissions can be prevented through educating and offer sufficient resources and supports through follow-up after their initial visit to the hospital. Assessing the hospital rate of admission is among the initiatives of improving quality of care. Based on a study carried out Jayakody et al. (2016), there was 4% rate of unplanned readmissions at 30 days while at 90 days it was at 7% after the initial visit of patients. The research project will help with the determination of whether education, sufficient resources, and support to the patients can be useful in reducing hospital readmissions for patients with diabetes mellitus before 30 to 90 days after discharge.

Summarize the Evidence and Intervention

Within a healthcare setting, providence of education, support, and resources alongside telephone follow-up are considered of great value because they are the best ways of providing advice and education, keeping in touch with patients, following up with patients about their symptoms as well as providing clients with post-care services (Harrison et al., 2013). They form part of fundamental and effective discharge planning, which help with the prevention of majority of readmissions. Similarly, patient follow-ups after an initial hospital visit also assist with issues of readmission (Jayakody et al., 2016). Every hospital is considered responsible for its health care spending (Martin et al., 2016). There will be the initiation of randomized controlled trials for patients with diabetes mellitus who have already been discharged within 90 days. The patients under study will be given a telephone call with the aim of confirming whether they understood their discharge instructions and are capable of accessing essential resources such as drugs. Telephone follow-ups will also be used to help with gaining an understanding of whether the patients are aware of their follow-up instructions and visits. Lastly, a comparison of the subject years’ patients’ readmission will be done to find whether future readmission rates would be reduced.

Potential Intervention

Since the prevalence of patients' 30-day readmission rate has been associated with the lack of proper health education, resources, and support to the discharged diabetes patients, effective interventions need to be put in place to ensure the high percentage of patient readmission is reduced. Apart from doctors making frequent follow-up calls, patients along with their family members will be required to receive additional education as well as written instructions, which would include strict compliance with dietary alongside the prescribed medication regimes.

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