Hospital Readmissions Reduction Program (HRRP)
In this task, you will experience the role of agraduate degree prepared nurse who is a Patient Care Transition Coordinator.For the purpose of this task, a Patient Care Transition Coordinator is definedas a nurse who focuses on assisting patients moving from the hospital to arehabilitation facility, and then to their homes. During this experience, youwill help specific patients move through different levels and types of care.You will identify the education, experience, and skills required for you toperform this role successfully. Additionally, as a Patient Care TransitionCoordinator, you should aim to prevent hospitalization and rehospitalization ofpatients who returned to their homes after hospitalization and rehabilitation.
In this task, you will experience the role of advancedprofessional nurse in the transitions of care from hospital to home orsub-acute or chronic facility:
The task is comprised of three phases of thetransitions of healthcare continuum for a patient. You will examine and discussevidence-based practices for a selected patient with one of the conditions orprocedures identified by the CMS Hospital Readmissions Reduction Program(HRRP). Patient scenarios for each of the conditions or procedures follow theinstructions.
The three phases on which you will focus are:
Transitionfrom hospital to home or sub-acute care facility
o Discuss the HRRP readmission reductionplan.
o Provide introduction to your patient anddiscuss pre-discharge initiative/interventions to promote optimal recovery andprevent readmission within 30 days or less.
Reductionof all-cause, non-disease-specific readmissions
o Research and discuss evidence-basedpractices for effectively transitioning patient from facility to home withspecific focus on preventing all-cause hospital readmissions.
o Incorporate social determinants of healthconsiderations that impact all-cause readmissions and how to prevent them withfocused interventions or initiatives for your patient targeting the individual,community, and system levels.
Primary,secondary, and tertiary strategies to prevent hospitalization
o Research and discuss approaches toimpact/reduce hospitalization utilizing primary, secondary, and tertiaryprevention initiatives focusing on the individual, community, and system levelspecific to your patients condition or procedure.
PHASE1: Evidence Based Practices for Effective Transition of Patient Care
Research the CMS HRRP (
PHASE2: Identifying EBP for the Prevention of Hospital Readmission
Researchthe evidence-based practices for effectively transitioning patients from thehospital (& rehabilitation unit) to home with the specific focus onpreventing all-cause hospital readmission. Utilize your textbooks, onlineresources, and other sources as needed.
Discussevidence-based practices focused on preventing all-cause hospital readmissions.
Incorporate individual, community, system, and socialdeterminants of health considerations that impact all-cause readmission and howto prevent them.
PHASE3: Development of a Hospital Prevention Plan
Based onresearch, create an extension of the HRRP that focuses on successfullypreventing hospitalization through primary, secondary, and tertiary preventionmethods.
Initiativesshould incorporate individual, social, community, system-level, and condition/procedurespecific considerations.
Advanced Health Assessment of Patientsand Populations CPE Case Scenarios
(one scenario broken down into the threephases)
Directions:
As the Patient Care Transition Coordinator, you are taskedwith effectively transitioning patients home and helping them to avoidreadmission to the hospital. Choose one of the following HRRPconditions or procedures patient scenarios and create a comprehensivetransition and prevention plan based on the information provided. Review theCPE Record document carefully for directions on completing the comprehensivetransition and prevention plan components for Phase 1, 2, and 3 of the ClinicalPractice Experience for this course.
Acute MI
Donald is a 55-year-old Hispanic male who is beingdischarged from the hospital after a 5-day inpatient stay for treatment ofacute myocardial infarction (MI). Five days ago, Donald felt chest tightness,nausea, and shortness of breath while gardening at home. After telling his wifeabout his symptoms, an ambulance was called and he was transported to the localhospital emergency department where the patient history, physical examination,and diagnostic tests were all strongly suggestive of acute MI. Within 50minutes of his first symptoms, Donald was in the cardiac catheterization labwhere an angioplasty was performed, and two cardiac stents were placed withoutcomplication.
During the remainder of his hospital stay, Donald startedtaking three new medications, received education about lifestyle modification,and began light walking on the unit. He will be discharged home today, withplans to see his cardiologist in two weeks, start cardiac rehabilitation in oneweek, and have laboratory blood draws in 5-7 days. Donald was followed by ahospitalist while receiving inpatient care and does not have an appointment tosee his primary care provider, who he last saw 7 months ago.
Donalds other history is as follows: Ht: 510 WT: 245 BP:116/78 Temp: 98.2 F O2 sats: 98% on RAPain: 1/10 at groin access point.
Insurance: Blue Cross Blue Shield
PMH: Hypertension for 15 years-treated withLisinopril. Obesity (BMI 35 kg/m2)-untreated. Hyperlipidemia untreated.Tonsillectomy at 15 years of age. Right knee ACL repair at 36 years ofage.
FH: Father deceased, MI at 62. Mother alive, 80, DMII, HTN, osteoporosis. Daughter, 20, alive and well, son, 17, alive andwell.
SH: Bachelors and Masters degrees in mathematics.Community college math professor. Salary of $75,000 per year with statebenefits. Married with two children at home. Wife works as an accountant. Homeis in a well-maintained neighborhood with sidewalks, a nearby park, and agrocery store 0.5 miles away. Donald usually eats at restaurants, the collegecafeteria, or fast food 6-8 times a week. Walks for exercise once a week for15-20 minutes. No smoking history. Drinks 2-4 beers on weekends socially, 3-4times a month. No illicit drug use. Two cups of coffee per day, and one regularcoke daily. Donald and his family attend a local church weekly, and are activeparticipants with local social groups. Extended family for both Donald and hiswife live nearby, within 30 minutes of their home.
Meds: Atorvastatin 80 mg tab, 1 tab daily by mouth.Atenolol 25 mg tab, 1 tab every 12 hours by mouth. Lisinopril 10 mg tab, 1 tabdaily by mouth. Clopidogrel 75 mg tab, 1 tab daily by mouth. Aspirin 81 mg tab,1 tab daily by mouth.
Allergies: NKDA, No food or environmentalallergies.
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