In the United States, nearly one-fifth of patients discharged from the hospital are readmitted within thirty days, and most of those readmissions are considered to be preventable (Verhaegh et al., 2014). Many opportunities to reduce health care costs and prevent readmissions could save Medicare as much as $12 billion a year (Constantino, Frey, Hall & Painter, 2013). These numbers are significant from a financial standpoint, but do not consider the negative impact on the patient’s experience, the perception of poor care quality and inadequate transitional care. Hospital readmissions may be linked to ineffective discharge planning, lack of care coordination, lack of outpatient follow-up care, client’s non-compliance with treatment regimen, inadequate …show more content…
Older adults with several comorbidities, care needs, complex medication regimens and treatments are especially vulnerable to breakdowns in care. Insufficient communication among providers across health care settings, inadequate patient and caregiver education, poor continuity of care, and limited access to services are among the major factors contributing to negative quality and cost outcomes (TCM, 2016). As a result, care coordination is the bridge between the chasm of evidence-based practices and current approaches to care (TCM, 2016). Patient related factors such as multiple chronic illnesses, those with CHF or COPD, and hospital readmission in the last six months were highly likely to experience a hospital readmission (Verhaegh et al., 2014). Care coordinators can partner with the patients to help reduce health disparities and reduce …show more content…
Patient follow-up after discharge is a critical component of discharge coordination. Follow-up call programs, especially those done by nurses, should be utilized to support discharge transitions and reduce readmissions by reinforcing health goals, providing patient teaching, assessing ongoing care needs, and evaluating patient satisfaction. In the Wee et al., 2014 article, the Care Transitions Program utilized care coordinators to provide coaching aimed at helping individuals and their families understand the individual’s condition, effectively articulate their preferences, enable self-management and care planning (Wee et al., 2014). During hospitalization, the care coordinator worked with families and other hospital staff to develop the most appropriate care plans and followed up with telephone calls and home visits hospitalization (Wee et al.,
According to Statistics Canada Report 2013, “life expectancy in Canada is one of the highest in the world” and it is expected to grow, making the aging population a key driver to our health-systems reform. By 2036, seniors in Canada will comprise of twenty five per cent of the population (CIHI, 2011). Seniors, those aged 65 years and older are the fastest growing population in Canada. Currently there are approximately 4.8 million Canadians aged 65 or greater. It is projected that this number will increase to 9 to 10 million by 2036 (Priest, 2011). As the population get aged the demand for health care and related services are expected to increase. Currently, the hospitals in Ontario are frequent faced with overcrowding emergency departments, full of admitted patients and beds for those patients to be transferred to. It has been reported that 20% of the acute care beds in the hospital setting are occupied by patients that do not require acute hospital care. These patients are termed Alternate Level of Care (ALC). ALC is “When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting (Acute, Complex, Continuing Care, Mental Health or Rehabilitation), the patient must be designated Alternate level of Care at that time by the physician or her/his delegate.” (Ontario Home Care Association, 2009, p.1).
In order to reduce Millie from frequent re-hospitalizations staff need to develop a plan. Millies discharge plan could include home healthcare, through proper collaboration, assessment, education, planning, interventions and evaluation. Home healthcare could provide Millie with companionship, meals, setup her medications, house cleaning, home safety evaluation, nurse assessments, tele-health, and help set her home up with medical adaptive equipment. Staff along with Millie’s daughter should be proactive in advocating for such needs (Hunt,
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
Hospital readmission can impact the patient, nursing practice, the hospital, and the health care system. The patient’s quality of life can be altered physically, psychologically, and economically (Whittaker, 2014) and recurrent hospitalization is a good predictor of increased risk of mortality (Hummel, Katrapati, Gillespie, DeFranco, & Koellig, 2013). Moreover, a patient in an acute care setting has an increased risk of contracting hospital-acquired infections such urinary tract infections, sepsis, C. difficile, and methicillin resistant Staphylococcus aureus (medicare.gov|Hospital Compare, 2013). Nursing practice is impacted as patients spend the majority of their acute care stay with the bedside nursing staff. According to...
When a patient is unable to make care decisions for themselves, it is necessary to involve those closest to them, most often family members. Providing a supporting environment to family members is another way that the best interest of the patient can be maintained. Families and friends can make a huge difference in the life of the patient after discharge. Instructing families in a way that is easy to understand helps eliminate potential barriers to communication. Families should be aware of what things to look for, what would constitute an emergency, and how to safely handle
With today’s technology and the specialized skills of doctors, nurses, and therapists, patients who need long term care of acute problems can obtain these services at institutions known as postacute care providers. One type of facility that falls under this title is the Long Term Acute Care Hospital (LTACH) (Munoz-Price, 2009, p. 438). This paper will discuss services provided by LTACHs, the role of the Chief Nursing Officer (CNO) in these facilities, and Medicare reimbursement effected by patient satisfaction surveys.
In efforts to address the health care needs of an individual with MCC, health care systems benefit from using the Chronic Care Model (CCM) and Transitional Care Model (TCM) when developing a patient care plan. The CCM predicts an increase in patients with self-management skills and tracking systems, by streamlining medical care through partnerships between health systems and local community assets (Mackey, Parchman, & et al., 2012). The TCM “emphasizes recognition of patient's’ health goals, coordination and continuity of care during acute episodes of illness, and development of streamlined plan of care to prevent future hospitalizations” ("Transitional Care Model," 2014, para. 1). Both models are successful with active participation of
Each day we are faced with making decisions regarding the plan of care and discharge of a patient based on the number of days an insurance company allows to treat the patient. Most times the days allowed are less than what is required to assist the patient back to their prior level of function and ability to safely return home. This causes an internal struggle for the provider and can lead to easily accepting what the insurance company allows even though it is not always best for the patient. Typically, we follow the rule of always doing what is right, which could mean that we keep the patient on the unit longer than the insurance will provide payment.
Patient-centered care is a broad topic that can be discussed on a daily basis within the healthcare world. Patient-centered care is when healthcare providers and facilities provide care that is respectful to the patient’s preferences, needs and values. It can also be described as physicians who practice patient-centered care can improve their patients’ clinical outcomes and satisfaction rates by improving the quality of the doctor-patient relationship, while at the same time decreasing the utilization of diagnostic testing, prescriptions, hospitalizations, and referrals (Rickett, 2013). Unfortunately, ideal patient-centered care is hard to come by, especially in all 50 states because there is a shortage of money and proper resources needed
In 2015, the Centers for Medicaid and Medicare Services (CMS) released the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which implements the final rule which offers financial incentives for Medicare clinicians to deliver high-quality patient centered care.5 Essentially, taking the time to learn the patient’s goals and treatment preferences allows for the patient to walk away from the medical treatment or service feeling understood and cared for by the provider.4 Thus, resulting in a better, more comprehensive plan of care. Policy makers are hopeful that the new incentive-based payment system will accelerate improvement efforts.
The chronic care model calls for an organizational change in the way individuals with illnesses are cared for, and the involvement of nurses, social workers and patients themselves. The challenge is moving in an effective way of improving quality from research carried out predominantly in health maintenance organizations to the mainstream of health care practice (Wielawski, 2006). Wagner’s explanation is to substitute the customary physician-centric office structure with one that supports clinical teamwork in association with the patient. The notion spreads outside the health care organization to collaborative associations in the community. Wagner et al. (2001) termed this approach the “chronic care model.” With this model, physicians, nurses, case managers, dieticians, and patient educators
According to our reading, Transitions are triggered by turning point events and for people with chronic illness, these can be predictable or unpredictable, cyclical and potentially recurring throughout life and result in the persons redeveloping their ways of living with illness (Kralik, Paterson, & Coates, 2010). Transitions of care refer to the movement of patients between health care practitioners, settings, and home as their condition and care needs change. For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility.
This project used a four person team to help manage the care of veterans on a more intimate level, such as making phone calls to their homes to find out how their day to day health is being maintained and if they have any current needs that the health care provider can help them obtain. As a result of reading their case study, I believe that having a healthcare group for each individual within a practice can also help address health care concerns of today. According to Porter and Lee (2013), this type of care would be called an integrated practice unit (IPU). In an IPU, a dedicated team made up of both clinical and nonclinical personnel provides the full care cycle for the patient’s condition. IPUs treat not only a disease but also the related conditions, complications, and circumstances that commonly occur along with it. IPUs not only provide treatment but also assume responsibility for engaging patients and their families in care by providing education and counseling, encouraging adherence to treatment and prevention protocols, and supporting needed behavioral change (p.11). By utilizing this type of group, it can provide better care for patients. This group would be made up of a medical doctor who will be the primary care physician and head of the group. A nurse would help follow up with the patient and continuing to help
OUTCOME/GOAL STATEMENT: Short Term: Pt will verbalize feelings of concern regarding at home maintenance of self with SO prior to discharge. Long Term: (after discharge) Pt will work with home health care giver to relief frustration and avoid further depression.
Hospitals, long term care facilities, and mental health all serve as healthcare arenas serving the population in various ways. The hospital provides the most critical type of care, for the seriously ill. Hospitals originally served the poor and ill, but over time with the progression of technology and medical service specialties, they have grown to become healthcare meccas with many outlets. Over the past 30 years the degree of rigor of clinical practice and the scope of scientific knowledge has escalated greatly, and the hospital has become a center of high standards, scientific applications, and advanced technological capability (Williams & Torrens, 2008). The increasing shift of services to an ambulatory care arena facilitated by technological advancement itself has left the hospital with an evermore complex base of patient care, higher acuity, and higher costs (Williams & Torrens, 2008). Markets have changed, pricing pressures have increased, and consumer and payer expectations have evolved for hospitals, changes are constant in the medical arena, and hospitals are no exception.