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...
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...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.
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