Evidence-Based Proposal Section-B Final 2 PDF

Preview

Summary

Evidence -Based Project Proposal ...

Description

Running head: EVIDENCE - BASED PRACTICE PROPOSAL – SECTION B

Evidence-Based Practice Proposal – Section B: Problem Description Grand Canyon University: NUR 699 November 2, 2019 Emma S Duquette

1

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

2

Evidence-Based Practice Proposal -Section B: Description of the Problem Background of Problem

The Centers for Medicare and Medicaid Services (CMS) promulgated the change in payment systems based on facility quality performance with different measures. The Hospital Readmission Reduction Program (HRRP) is a Medicare value-based acquiring program that cuts down payments to healthcare facilities with high readmission rates (cms.gov.2019). Improving healthcare is a fundamental national objective and this program underpins this goal by associating payments to the quality of care (cms.gov.2019). Leaders within this organization stratified effective interventions and have heightened their efforts to combat this overarching problem to avoid financial penalties, improve care, decrease cost and improve the patient’s experience. Heart failure (HF) is recognized as one of the dominant causes of rehospitalization and an utmost healthcare burden (Ziaeian & Fonarow, 2016). The Heart Disease and Stroke Statistics Report from the American Heart Association approximates that pervasiveness of HF is 5.7 million with one million hospital admissions caused by HF (Chamberlain, Sond, Mahendraraj, Lau & Siracuse, 2014). American adults surviving with HF is expected to rise to 46% in the next decade with more than 8 million adults living with this chronic disease (Ziaeian & Fonarow, 2016). According to this article, the total cost of HF in one particular year was $30.7 billion and this condition became the number one diagnosis for hospitalization. Because of insufficient treatment, discharge instructions, and follow-ups, an approximate 24 percent of patients who are discharged are readmitted to the hospital within 30 days (Regalbuto, Maurer, Chapel, & Shaffer, 2014). JACHO demands for comprehensive strategies to reduce HF

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

3

readmission focusing on discharge instructions. An EBP must be deployed to alleviate this pressing public health problem. Change Agents and Stakeholders For the implementation of this project within the organization the stakeholders are the SNF administrators, director of nursing services, unit managers, social workers, medical directors, cardiologist, therapists including physical, occupational and respiratory therapist, home care services nurse practitioners and heart failure skilled nursing home patients. The nurse navigators established their own system and processes to alert the facility when patients with heart failure are readmitted to the hospital within 30 days after discharged from SNF. The change agent will be the nurse practitioner’s involvement in the management of HF while the patient is in the SNF and post discharge during homecare visits. The Trinity Health network is concerned about this new initiative and the proposed SNF’s staff will be affected with this change. Patient and family members will benefit and experience better care and attention. CMS will be interested in looking at the results due to the incentives for the high performing organization and monetary penalties for those with substandard outcomes and worst-performing homes. These incentives and cutbacks are designed to prevent SNF from discharging patients to home prematurely and to ensure that discharges are planned appropriately with homecare services (Rau, J. 2018) PICOT Question (P) In heart failure skilled nursing home patients, (I) how does the addition of a nurse practitioner weekly visit with education, (C) compared to homecare visit with a nurse and therapist on an intermittent basis, (O) impact heart failure progression and rehospitalization, (T) within 30 days after discharge from skilled nursing home? Project Purpose and Objectives

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

4

Many Medicare beneficiary patients are admitted to nursing homes from acute care settings such as hospitals with diagnosis of HF and other multiple co-morbidities. They are admitted mainly for skilled nursing services, disease management and stabilization, and skilled therapy treatments for physical strengthening and safe mobility. The purpose of this project is to reduce the rehospitalization rate in one of the SNFs owned by Trinity Health Senior Living Communities, one of the largest health care organizations in the country. This proposed facility has a 0.97% rate for unplanned rehospitalization which is higher than the organization’s benchmark. The fundamental objectives of this project are geared towards improving patient’s outcome, patient’s experience including quality and experience, improving the health of the population and reducing cost of health care (Brooks, K. 2012). The rehospitalization prevention project within 30-days of admission to SNF and after discharge to the community is a systematic approach and methodology to avoid financial penalties and to improve the overall quality measures at a national level. This project will include multidisciplinary collaboration, on time communication, reorganizing the clinical structure to include a fulltime nurse practitioner (NP) in the facility and incorporating NP visits with homecare services post discharge to follow up patient’s adherence to medication and ongoing patient’s disease management and education. The home care program will include NP as part of their organization structure. In addition to this change, the Intervention to Reduce Acute Care Transfer (INTEACT) tool will be implemented through training and education of staff. The INTERACT tool has been proven effective across the country with a 24% reduction of all-cause rehospitalization of nursing home residents (Ouslander, Bonner, & Shutes, 2014). A Heart Failure toolkit will be incorporated and must be followed, monitored and evaluated from patient’s admission to SNF and 30-days following patient’s discharge to home setting. The tools that will be utilized are Stop and Watch, SBAR,

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

5

Medication Reconciliation and CHF Care Path. These tools will enhance nurse and NPs communication regarding a patient’s status. A tracking mechanism to monitor patient’s progress as in-patient and out-patient for 30 days will be employed. The purpose of the utilization of these tools is for nursing staff to assess and recognize early signs of heart failure and to communicate any change in a patient’s condition to the NP so that immediate medical intervention is implemented to mitigate risk and symptom exacerbation that could lead to rehospitalization. The objective of the project is to avert 30- day readmission among heart failure patients in a skilled nursing facility and after discharged to a home environment. To accomplish this objective a NP is a valuable addition to the clinical team to manage and treat patients while in the facility and will follow up patients in their most fragile state after discharge home on a weekly basis. With this implementation, any potential noncompliance to this project will be immediately addressed and mitigated for a robust outcome. The comparison of informational data collection will be compared and evaluated within a ninety-day period. This will be applied to compare and analyze the NP integration of care as well as the use of INTERACT tools to assess rehospitalization events. The project team leader and interdisciplinary (IDT) members need to evaluate and ask the following critical questions. 1. Were early signs and symptoms of HF exacerbation identified using the CHF toolkit? 2. Is the communication process between the nurse and NP efficient to have mitigated risks that could lead to a patient’s rehospitalization? 3. Is adding a NP to the clinical team impactful in preventing 30-day rehospitalization during the SNF stay and post discharge to home setting? 4. Is the HF care path utilized optimally having prevented patient’s rehospitalization?

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

6

Furthermore, the comorbidities will be assessed and monitored throughout this project implementation. Examining the hypothesis and the description of the initial problem and tracking progress report shall disclose how effective the result of the project. The outcomes from the first implementation as well as the feedback from the senior executive leaders will decide the next phase and deployment timetables for implementation to the remaining SNFs within the Trinity Health organization. Supportive Rationale An article published by Jones, DeCherrie, Meah, Hernandez, Lee & Skovranin in (2017) endorsed, NPs working with a geriatric IDT team has improved health outcomes and has decreased acute care utilization of those high risks for readmission such as HF. According to this article, there is present evidence to support that a NP co-management approach improves the patient’s health condition in various settings. Moreover, according to Ouslander et al (2017) the INTERACT tool is a quality improvement program that directs towards enhancement of the management of sudden acute changes in condition that prevents rehospitalization in circumstances where situations that can be efficiently and safely managed in the nursing home. The percentage of patients with 30 day-readmission with the co-management model decreased from 17.2% to 5.8% and most of the study sample was not hospitalized during the study period. The mean number of hospitalizations in the study population reduced from 1.38 before comanagement to 0.74 after enrollment in the program. Additionally, annual hospitalization rates were significantly reduced from 2.27 before co-management to 1.26 post management (Jones et al., (2017). Hence, incorporating NPs in management of clinically complex patients is associated with reduced rates of hospitalization and 30-day readmission and provider satisfaction with the program is ranked high (Jones et al., 2017).

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

7

Initial Reference List The evaluation of change with the project implementation will be supported by an evidence-based literature review. Jones et al (2017) disclosed the published data offer limitation because co-management was not compulsory for patients with specific symptom burdens or rehospitalization rates. Having said this, there is no unbiased data analysis published in the report as this are crucial to maintaining the effectiveness of EBP (Jones et al., 2017). A systematic review study on the efficacy of continuity of care and its significance in patient satisfaction and decreased readmission in patients receiving home care services concluded that home care interventions that comprise nurses, advance practice nurses with specialized training such as NPs in the care of the HF population served as the direct provider along with collaboration with a multidisciplinary team contributed to reduced hospital readmission rates (Santomassino, M.2019). The result of the included studies recommends that the employment of an advance nurse with expertise in a disease processes with IDT is impactful in reducing readmission rates and patient satisfaction (Santomassino, M.2019). Another systematic review and meta-analysis of randomized study trials conducted for preventing 30-day hospital readmissions published that physical visitation by intervention providers to the patient’s home environment is crucial to health maintenance and well-being (Leppin, Gionfriddo, Kessler, Brito, Mair, Gallacher, 2014).The initial reference list of and literature as well as sources of information to support evidence-based proposal are: Hospital Readmissions Reduction Program (HRRP) - Centers for Medicare & Medicaid Services. (2019). Cms.gov. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/Acute In patient PPS/Readmissions-Reduction-Program.html

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

8

Ziaeian, B., & Fonarow, G. (2016). The Prevention of Hospital Readmissions in Heart Failure. Progress In Cardiovascular Diseases, 58(4), 379-385. doi:101016/j.pcad.2015.09.004 Chamberlain, R., Sond, J., Mahendraraj, K., Lau, C., & Siracuse, B. (2018). Determining 30-day readmission risk for heart failure patients: The Readmission After Heart Failure scale. International Journal of General Medicine, Volume 11, 127-141. doi:10.2147/ijgm.s150676 Regalbuto, R., Maurer, M., Chapel, D., Mendez, J., & Shaffer, J. (2014). Joint Commission Requirements for Discharge Instructions in Patients with Heart Failure: Is Understanding Important for Preventing Readmissions? Journal of Cardiac Failure, 20(9), 641-649. doi:10.1016/j.cardfail.2014.06.358 Rau, J. (2018). Medicare Cuts Payments to Nursing Homes Whose Patients Keep Ending Up In Hospital. Kaiser Health News. Retrieved from https://khn.org/news/medicare-cuts-payments-to-nursing-homes-whose-patients-keepending-up-in-hospital/ Ouslander, J., Bonner, A., Herndon, L., & Shutes, J. (2014). The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care. Journal of The American Medical Directors Association, 15(3), 162-170. doi:10.1016/j.jamda.2013.12.005 Jones, M., DeCherrie, L., Meah, Y., Hernandez, C., Lee, E., & Skovran, D. et al. (2017). Using Nurse Practitioner Co-Management to Reduce Hospitalizations and Readmissions Within a Home-Based Primary Care Program. Journal For Healthcare Quality, 39(5), 249-258. doi:10.1097/jhq.0000000000000059

EVIDENCE-BASED PRACTICE PROPOSAL SECTION – B

9

Santomassino M, e. (2019). A systematic review on the effectiveness of continuity of care and its role in patient satisfaction and decreased hospital readmissions in the adul... - PubMed – NCBI . Ncbi.nlm.nih.gov. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27820460 Leppin, A., Gionfriddo, M., Kessler, M., Brito, J., Mair, F., & Gallacher, K. et al. (2014). Preventing 30-Day Hospital Readmissions. JAMA Internal Medicine, 174(7), 1095. doi:10.1001/jamainternmed.2014.1608

Conclusion: The evidence established that continuity of care model which includes utilization of home care services along with patient and provider coordination has a positive correlation with improved patient’s experience and hospital readmission. Home health care, where patients receive care from multifaceted healthcare practitioners provides strong evidence that this proposed project is a highly evidence-based practice that will improve patient’s care, decrease hospital readmission and enhance the patient’s experience and decrease health costs....