Congestive Heart Failure: Improving Hospital Discharge Planning - Research Proposal Example

Congestive Heart Failure: Improving Hospital Discharge Planning Introduction/hypothesis CHF (congestive heart failure) is a serious affliction that affects many individuals. The importance of studies on CHF is vital, because many Americans, particularly the elderly, suffer adverse effects, and need post-treatment care. The purpose of the proposed study is to make discharge planning more efficient and better for the health of the patient with CHF, focusing on the Miami area. Hospitals must realize that cutting corners in regards to effective discharge planning, particularly for CHF patients, can mean short-term gains bringing vastly increased future costs. “Hospital admissions among patients with CHF are a major contributor to health care costs…The program's aims were to make up deficits in health care delivery, improve quality of life, and reduce costs for the health insurance companies (e.g., by reducing the hospitalization rate [Stewart, Marley, and Horowitz, 1999; Whellan et al., 2001; Cline et al., 1998])” (Kottmair et al., 2005). Therefore, the purpose of this study proposal is to advocate effective discharge planning for patients with CHF as highlighted in the current healthcare environment, for the provider to ensure the continued provision of quality care across the lifespan of the client. The area of concern for the proposed research is that of the hospital, not the nursing home; both have high instances of CHF cases. “Better decisions about where to discharge patients could improve the course of many patients. It is possible to save money by making wiser discharge planning decisions. Nursing homes are generally associated with poorer outcomes and higher costs than the other post-hospital care modalities” (Kane et al., 2000). Different environments will often lead to extraneous variables. Hypothesis The basic assumption that the current proposal confronts is that patients with discharge instructions and proper follow-up will have fewer readmissions longitudinally. We further hypothesize that early discharge instructions and appropriate follow up could significantly reduce the rate of readmission for elderly patients at high risk for CHF recurrence. Sample selection Inclusion and exclusion criteria for the sample will be based on factors of the individual’s proximity to care of CHF patients. CHF patients selected for the group will be in the elderly category, with age above sixty, admitted to Jackson Hospital in Miami with a diagnosis of CHF. Therefore, at the hospital, for sampling the researcher will select representative units from two cross sectional populations: the CHF patients and a control group. Using the survey format follows the actors approach of sampling, in which the researcher is interacting with participants in a controlled quasi-experimental sample rather than trying out some obscure and hidden theory on them. One important question for the sampling group is: does an effective discharge planning program reduce hospital readmission for CHF patients? A related question could be: would an improved health report system improve outcomes in terms of quality of care? These questions can be answered, using sampling and other research models. “Probability sampling avoids conscious or unconscious biases in element selection on the part of the researcher… (and) permits estimates of sampling error. Although no probability sample will be perfectly representative in all respects” (Babbie, 1995, p. 224). The method of the proposed experiment will be a combined questionnaire and interview of the patients versus a control group to measure outcomes. Differences in groupings The diferences between the control group, and the intervention group are associated with which group presents demographic information. Control group investigation will be the hospital’s normal program for discharge planning, and the intervention group will be a pilot program that is based on raising patient education and awareness about CHF and lifestyle choice. The control group will not have this intervention. Instructions will be given by a nurse with a master’s degree, and two years’ experience treating patients with CHF. The follow up will be conducted with a home health agency, and visits and phone calls will be scheduled after receiving the consent of the participant. About site In Miami-Dade County, Florida, the major hospital is Jackson Memorial. This is a well established hospital with outreach programs. There are various clinics in Miami as well, some of which cater to immigrant populations like the Haitian community. “Jackson Memorial treats the poor and uninsured, as well as patients requiring specialized care. 1,567 licensed beds regional referral center for Jackson Health System's network of 12 primary care providers. Burn center; Newborn special care center; Organ transplant center” (Miami, 2009). CHF patients are common at this hospital, as at others in the nearby proximity. The site contains professionals who are trained in dealing with patients who have CHF. Consent procedure The participants in the study will be asked if they want to participate; if they decline, this will be respected. They will be given the option of anonymity and confidentiality as well to increase data collection quantity. Data will be collected and tabulated according to responses to the two basic types of questions on the survey: multiple choice answers and text or short answer style responses from the participants. The data that is garnered will be stored on computer discs which will be able to be destroyed after the research is over, to protect the precious and vital anonymous survey information from falling into the wrong hands and causing a general disaster. Data will also be used to construct various charts and graphs showing the attenuation of the results to the original hypothesis. Instruments The instrument for the proposed research is not one that has been used before as a standard, but it is a survey that is planned logistically to measure how patients managed to reduce readmissions with proper discharge instructions, by looking at survey responses from healthcare facility patients of Jackson Hospital. In terms of validity and reliability, it is potentially increased by the fact that this is not something that respondents are forced or coerced into doing, and they are informed that participating in the survey is voluntary, so that if they have comfort issues, they will not have to take the survey, and can instead opt out. Literature review There is a lot of literature on patients with CHF being readmitted, and how hospitals can improve discharge planning procedures. For example one study looks at the use of health reports in effective discharge planning. The authors of this study state that, “Health reports provide feedback for the patient and his physician on a regular basis (examples are available on request from the author). The nurse discusses the reports with the patient during the care call…. The report also contains a reminder of the next medical examination. As a written document, the health report supports the patient's compliance in the process of care and strengthens abilities for self-management” (Kottmair et al., 2005). In another study, “Investigators at the University of South Carolina Medical Center (USCMC) studied the effects of a nursemanaged heart failure clinic on patient readmission and length of stay. They used a clinical pathway to monitor patients' progress. This pathway included cardiopulmonary assessment, daily weights, education on medications and sodium-restricted diet, assessment of medication compliance, and assistance with financial constraints” (King, 2001). CHF is often talked about in the existing literature as a condition that particularly affects the elderly. It must be remembered that CHF can strike at different age stages, but it is most prevalent among the elderly in terms of its epidemoiology. “It is common for older people with congestive heart failure (CHF) to be readmitted to hospital within six months of hospital discharge. In the USA, up to half might expect to be readmitted, and it is stressful for the patients themselves, as well as consuming considerable resources” (Discharge, 2005). The existing literature on the the subject of CHF discharge planning tends not to be politically or socio-economically motivated. In Kane et al.’s study, which is an experimental study, different modalities of after-care for conditions like CHF are observed, and the authors use an experimental study to determine which groups did best based on setting. From these authors’ perspective, discharge planning is an important part of the process based on its proximity to where the patient is, in relation to their situation. “In general, patients discharged to nursing homes fared worst and those sent home with home health care or to rehabilitation did best. Because the cost of rehabilitation is high, greater use of home care could result in improved outcomes at modest or no additional cost” (Kane et al, 2000). Many sources advocate homecare because it is the most cost effective intervention, so this could lead to influential factors of bias in the research. Li et al.’s study points out gaps in the existing knowledge structure about effective discharge planning, particularly in relation to CHF cases. “Despite the involvement of informal caregivers and formal service providers, researchers have not paid sufficient attention to the effects of informal and formal home care services on elderly patients' outcomes during the post-acute period (Kane, 1996)” (Li et al., 2006). Note that in this source, as mentioned above in other sources, the presentation of the patient population for CHF is presented as being elderly, focusing on this age stage in the current research investigations, for the most part, in some cases explicitly and in other cases more implicitly. “A substantial literature reflects assumptions that the product of discharge planning should be care arrangements that meet patients' needs and prevent early readmission to acute care facilities” (Proctor et al., 2000). There are many perspectives on the issues. Hoke et al. put CHF inot perspective before performing their own empirical investigation. It is important to view this study proactively because it sets up the framework for investigations in to CHF such as the one proposed, in terms of common factors and statistics. “In the United States, over 400,000 people are diagnosed with congestive heart failure (CHF) each year. CHF is a common clinical syndrome associated with a high incidence of mortality, morbidity, and hospital readmission in older adults” (Hoke et al., 1997). Many of the factors that contribute to high cases of CHF are modifiable, making this a disease or condition that is strongly affected by behavioral and lifestyle choices that a patient may make, such as cutting down on the intake of food or quitting smoking. Some of the literature is specific about discharge planning for CHF patients, and others are more general. Mostly, the literature on this subject shows that patient and staff education are very important to achieving desired outcomes of patient quality of care and cost effective management in the healthcare structure. It is hoped that increasing reform will make the healthcare system more one of equal access to all under new programs. There are also new devleopments with pharmaceutical or pharmacological interventions with CHF patients, as mentioned in Moon’s review. “Before the program was implemented in January 1999, 63% of patients eligible for ACE inhibitor therapy and 57% of those eligible for [beta]-blocker therapy received prescriptions for those drugs at discharge. These "dismal" rates are similar to those reported at other hospitals across the country” (Moon, 2002). There are many things that hospitals can do to improve CHF discharge planning. Kubetin did an experimental study about gender and CHF, which can also be related to results in terms of the gender of those patients being surveyed. “The gender disparity was greatest among the oldest patients, with discharge rates for women being two- and threefold higher than for men at ages 80-85 and greater than 85, respectively, she said at the annual meeting of the Colorado chapter of the American College of Physicians--American Society of Internal Medicine” (Kubetin, 2000). Therefore, cues from this research experimentally can also be followed in terms of targeting elderly indiviudals for participation, because they tend to have higher rates of CHF in epidemiology of the condition. “As of October 1, 1998, a distinction is made between discharges in which patients have completed treatment and discharges in which patients are transferred to other institutions for related care under the prospective payment system (PPS). Payment for the two situations differs” (Gundling, 1998). This shows an external perspective of the issues. Nazreth et al. also explore the intestice of CHF and discharge planning, and find new technological solutions. This brings up related issues of electronic health records and other changes that have been occurring recently in the swiftly changing healthcare environment. “The report draws two central conclusions: (a) there is a need for more comprehensive and linkable hospital discharge databases, and (b) state-wide data organizations need greater support as they develop their abilities in advanced analysis and reporting” (Nazreth et al., 2001). This is experimental data, presented in the form of statistics, just as in the CPOE source. “For patients with congestive heart failure (CHF), provision of discharge instructions improved from 3 percent to 56 percent, and provision of smoking cessation counseling rose from I percent to 43 percent for the CHR patients. For patients recovering from an acute myocardial infarction (AMI), smoking cessation counseling rose” (CPOE, 2006). This shows statistical results which can be seen as empirical or experimental. Methodology A quasi-experimental survey methodology will be conducted to give quantitative results in the proposed research. Data generation will be accomplished through both interview and survey methods. The descriptive phase of the quasi-experimental design follows, in which the demographic and statistical information on the target population and target program emulations are determined in respective forms of their completeness and efficiency as representative statistics and discharge planning models. In the explanatory phase which follows this in turn, the actual research of the experiment itself will employ salient variables and determine relationships answering the overall questions of why and how. A clear question is how the interview of healthcare professionals will proceed in the proposed research to generate data. The proposed methodology will include the provision of non-spurious interrelationships that have been shown by the experiment, and these relationships will be examined in terms of how they apply to future studies on the subject of congestive heart failure, effective discharge planning, and healthcare facility structural influences. This research will provide complete and detailed information relative to the issues surrounding effective discharge planning. A quasi-experimental design is deemed to be appropriate for the current research, with limited ethical effects of having to measure different CHF populations while administering different levels of care and follow-up; it is the ethical solution to the general premise. It is the assumption of this report that the survey element may bring up issues that are not demonstrated adequately in the existing literature on the subject. Ethical questions of the research here involve the participation in interviews by permission, and informed consent, as well as the condition of voluntary anonymity. Correlations will be formed between respondents relative agreement with the hypothesis and their age, income level, and level of education. Theoretical framework The health belief model is based on how people will respond to illnesses like CHF, and seeks to look at the patient from a psychological perspective. From this point of view, the patient is seen as making choices based on desired outcomes, whether something represents a risk or a benefit to them in a psychological calculation influenced by factors of susceptibility, severity, benefits, and barriers. Based on these factors, the patient is either ready to act on an illness or not, in various ways. This is an effective theory to view CHF, because of the nature of the illness, as well as because of the perceived severity of after-care, with after-care also being the major barrier, in this theoretical situation. Theory can also be applied in terms of the general healthcare situation acting as a barrier to the patient. The main problem is that under the current managed care system, may patients with CHF are not getting effective discharge planning. This is because the system concentrates on costs to the hospital instead of providing quality of care to all patients. There are a lot of bad hospitals out there that leave the patient worse than when they came in, or don’t tell the patient vital information that could save them from a trip back to the hospital for the same procedure. This is a major problem in the current environment that could affect the very future of all research efforts, so it is important to address it. The purpose of the proposed study is to increase quality of care for these patients and increase patient education so that clients know more about CHF risk factors and behaviors that should be avoided. The study also will deal generally with issues of how discharge planning should be handled to make sure that all clients get the right information. This is because, as Pothoff states, “For the older patient, the discharge from a hospital is a critical juncture, when decisions are made that may influence the rest of that person's life. Discharge planning is a challenging task under the best of circumstances, and changes in the health care environment have made it almost impossible to do such planning well” (1997). Therefore the major goal of this proposal is to go against these odds and do effective discharge planning. “From the perspectives of cost and quality of care, early readmission to acute care is viewed widely as one of the most serious problems in health services and one that discharge planning can help prevent” (Proctor et al, 2000). From a theoretical perspective, it is important to measure factors and variables. Conclusion The proposed research will be a quasi-experimental survey design which seeks to measure prevalence of CHF patient after-care affecting readmission rates. The survey will take place at Jackson Hospital in Miami. Respondents and participants will be informed of consent procedures and confidentiality of results will be ensured by destruction of the data after the research has been carried out. The literature on the subject shows the need for research into CHF and after-care, as well as future research being needed on preventative care. REFERENCE Babbie, E. (1995). The Practice of Social Research. New York: Thompson. Gundling, R (1998). Hospital transfers and discharges redefined. Healthcare Financial Management. Hoke, L, S Kagan, and K Craig (1997). Weighing behavior and symptom distress of clinic patients with CHF. MedSurg Nursing. Kane, R, Q Chen, M Finch et al (2000). The Optimal Outcomes of Post-Hospital Care Under Medicare. Health Services Research. King, L. (2001). RATs improve heart care. Nursing Management. Kottmair, S., C. Frye, D. Ziegenhagen (2005). Disease management program: improving outcomes in congestive heart failure. Health Care Financing Review. Li, H, N Howell, E Proctor (2004). Post-acute home care and hospital readmission of elderly patients with congestive heart failure. Health and Social Work. Moon, M (2002). Standardized prescribing reduced CHF readmissions. Internal Medicine News. Nazreth, I, A Burton, S Shulman e tal (2001). A pharmacy discharge plan for hospitalized elderly patients—a randomized controlled trial. 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