The Type Of Healthcare ( Hc ) Service

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The type of healthcare (HC) service: I would like to develop a Continuing Health Management program/team that focuses on preventing readmission. The CHM team of nurses would offer follow up services to recently discharged patients in helping them to locate primary care physicians in their area, locations of mobile clinics, medication compliancy, education, and preventive services. The CHM health care service will offer both restorative and preventative services, the two general types of HC services (Yoder-Wise, 2014). Working in the medical intensive care unit, we see a great deal of readmissions in our unit due to patient’s lack of follow up care with their primary care physicians, medication compliance, and education. Rationale for my desire to establish a Continuing Health Management program/team is based on need: The Journal of the American Medical Association has published various journal articles studying the impact of how coordinating care in the hospital and after discharge can greatly decrease the risk of readmission for patients. Research indicated that communities that utilized community based transition outreach programs greatly reduced the risk and cost of readmissions among Medicare patients verse private pay. Length of service and types of clients served: The CHM team will provide set up follow up appointments prior to discharge for patients with in network PCPs. 1-4 weeks post discharge. If patients are in rural areas appointments will be made with mobile clinic servicing the patient’s area. Appointments with Doctors name, number, and address will be provided with discharge paperwork. Team will be assigned to high risk patients and follow up with patients post their follow up PCP appointment to confirm their a... ... middle of paper ... ...re patient safety policies are being upheld with the highest of expectations. CHM program will operate both in hospital and outside the hospital in the community. Whether in hospital or during patient education in the community CHM nurses will be expected to follow all TJC polices regarding patient safety goals (www. Jointcommission.org). Quality Indicators with evaluation plan: CHM will utilize The National Database of Nursing Quality Indicators over the period of 90 days to gather data on the discharge of high risk patients with CHF, pneumonia, DKA, and acute MI. Data that will be collected will include the amount of readmissions within the 30/60/90 days, obstacles to locating PCPs, medications, educations, and community resources. http://www.hin.com/gifs/conditions_reduce_readmissions2.jpg http://www.hin.com/gifs/2012_reduce_readmission_barrierslrg.jpg
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