Transitions of Care Program - Essay Example

Evidence Based Proposal Healthcare costs have increased so rapidly that it is impossible to keep up. The organization of the healthcare system is being scrutinized at every level. Quality of healthcare is a greater expectation than ever before and the need to assure that the healthcare received is evidence based. Evidence based healthcare is research based healthcare and requires more than the development of a policy. Here is discussed the Transitions of Care program which is a coordinated care program that is evidence based and uses the theory that one of the largest issues in healthcare today is the lack of organized communication. The evidence definitely supports the use of this program and s presented in this paper. Evidence Based Proposal Continuous quality problems and spiraling costs in healthcare have lead to widespread interest in solutions that are effective and well supported. Evidence based practice has taken hold as an answer to the problem that makes sense (Coleman, 2003) EBP is sometimes viewed as an ideology, however, as far as practice goes it's goal is to supplement professional decision making with the latest research. It is sometimes argued today that to treat someone with a practice that the efficacy has not been shown is not ethical (Kind,2007). That would leave many healthcare treatments today as unethical. This paper will discuss nursing transition to evidence based practice in the realm of patients and transitioning. The question would be, "What are the most effective interventions for improving care coordination" Many Medicare dollars are spent on a small percentage of beneficiaries with chronic conditions and those people are in and out of the hospital many times, many within short periods of time. The causes of this are numerable but some of them are inadequate care, poor communication among primary caregivers, specialists, and patients, weak adherence by patients, and failure to catch problems early. There are three types of intervention being looked at closely at this time to try to solve these problems. Transitional Care, self managed education intervention, and coordinated care interventions are being considered as effective but requiring further study (Coleman, 2003). Transitional care is first engaged in the hospital, followed intensely post-discharge and receives comprehensive post discharge instructions on medications, self care and symptom recognition. Reminder calls are made to assure that the patients follow up with primary care providers as required. Effective transitional care is targeted for patients with specific diseases such as CHF. This is guided by APN's and is usually a twelve week intervention that is highly structured with protocols (ncga.gov.) It requires a one year post discharge follow-up. Statistically it has shown to reduce hospitalizations by 34% and lower overall costs by 39%. APN's in this case are the transitional coaches and there are tools given for cross site communication. Self management education is a term used for collaboration with patients and families to identify patient goals, improve self management, expand sense of self efficacy, and assess mastery of skills (ncga.gov). Much of this is done in group sessions of limited duration. The targeted patients are usually forty or older and have heart disease, lung disease, stroke or arthritis. There are usually seven weekly group sessions on exercise, symptom management, techniques, nutrition, fatigue and sleep management, use of medications, dealing with emotions, communication and problem solving. Statistics show that these patients have 1/3rd fewer hospital stays. Coordinated care on the other hand is considered teaching patients about self care, medications, how to communicate with problems, monitor patients symptoms, well-being, and adherence between office visits and advise patient on when to see their physician. A full report is given to the patient's physician (ncga.gov). This would also include arranging for social support services. The goal here is to reduce need for any hospitalization, don't wait till late in care, and providing an ongoing contact for chronic illness. Of these three descriptions, this paper will show research on Transitional Care and develop an EBP based on that research. The target population will be patients greater than the age of sixty who have been admitted to the hospital more than once for a disease that requires severity of health transitions patterns. Transitional care has been put into place by many institutions. It is defined as a set of actions that ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care with the same location. It is based on a comprehensive plan devised by professionals that have a unique understanding of the problem and process (Coleman, 2003). Patients who's disease necessitates complex and continuous management require the need to be seen by many different kinds of healthcare professional. Patients have a greater chance for risk during these transitions, systems of care often fail and important elements of care that were put together in one setting may not be known at all in the next setting. This all causes risky care as well as slower and more expensive care. Patients who have received poor transitional care are readmitted to the hospital often, having repeat test, including expensive x-rays and a multitude of other adverse results. Effective transition programs have been put into place and during that phase, effective elements of care transition have been noted (Coleman, 2003). These include: 1. Communication between the sending and receiving clinicians regarding: a. A common plan of care b. A summary of care provided by the sending institution c. The patients goals and preferences d. an updated list of problems, baseline physical and cognitive functional status, medications, and allergies e. Contact information for the patients caregivers, and primary care practitioner. 2. Preparation of the patient and caregiver for what to expect at the next site of care. 3. Reconciliation of the patient's medication prescribed before the initial transfer with the current regimen 4. A follow-up plan for how outstanding tests and follow-up appointments will be completed 5. An explicit discussion with the patient and caregiver regarding warning symptoms or signs to monitor that may indicate that the condition has worsened and the name and phone number of who to contact if this occurs. (Magilvy & Congdon, 2000). Evidence based practice cannot be designed without research. Care transitions research was completed by Magilvy & Congdon ( 2000). The problem was a rural health care problem for older adults. The American healthcare system causes many issues for rural residents who are already at high risk for disease and disability. Magilvy et.al. (2000) employed an ethnographic design that was conducted within the culture and context of the rural western United States. This was through a group of interviews, participant observations, photography, examination of cultural artifacts, and ethnographic analysis (Magilvey, & Congdon, 2000). The ethnography was set in thirteen counties located in two areas of rural Colorado. The areas studied had a small regional hospital, high numbers of people over sixty five and low populations. The study was conducted over four years and followed one hundred and seventy five patients. The results showed that under these circumstances, it usually takes a crisis or an admission to a hospital for these patients and families to plan. Planning does not occur until the patient can no longer plan and because the families have not planned with them, no one is able to make a decision in the patients healthcare (Magilvey, 2000). Difficult decisions such as transitioning from the hospital to nursing home, home to nursing home or hospital to home was difficult because of lack of planning. To compound this, there are constantly changing reimbursement issues in which patients and their families do not receive education and do not understand. One example was a patient that got no help because she did not know that Medicaid would provide her with the help she needed at home. Further, they found that patients and families under these circumstances were not aware of resources in their community or communities around them and were not receiving that information on discharge from their hospitals. In these rural hospitals, it was found that discharge planning was inconsistent and not only was this process not done by a RN, it often was not done by a nurse at all. This consistent lack of in depth discharge planning and the limited knowledge of community resources led to frequent transitions for the patient as well as frequent admissions. Rural home health care was identified as a strength however but the information needed was not always passed to them in an organized way (Magilvy, et.al., 2000). In the end the study continued to show that difficult and poorly executed health care transitions were creating major risk for these rural elder residents and though home health services were prepared to handle some of the transition, the system was poorly supported by the rest of the healthcare team. This study supports the need for a well developed transitions care program. This was further supported by study in 2004 by Coleman, Smith, and Frank. Their objectives were to test whether an intervention designed to encourage older patients and caregivers to assert a more active role during care transition can reduce readmission rates at the hospital (Coleman, Smith, & Frank, 2004, pg 1817). Older adults moving between different healthcare settings are particularly vulnerable to receiving fragmented care. Problems include such things as conflicting recommendations, confusing medication regimens with a high potential for error and duplication, lack of follow-up care, and inadequate patient and caregiver participation or preparation for receiving care (Coleman, et.al., 2004). This was a quasi-experimental design in which 158 subjects were compared with 1,235 control subjects that were derived from administrative data. A large integrated healthcare system in Colorado was studied. The participants in the study were people who lived in the community, were at least 65 and were admitted to the hospital with one out of nine preselected conditions. The intervention subjects received transitions training and cross site communication tools and guidance from a transition coach which was an APN. The conclusion was quite positive. Those patients who participated in the care transitions role had reduced rates of hospitalization and re-hospitalizatio (Coleman, 2004). These interventions worked well and also reduced the numbers of medication incidents that required admission to the hospital. Further, intervention subjects were significantly less likely to have experienced a stroke, hip fracture, or coronary artery disease yet had a higher burden of co- morbidity. In follow up with the medication issue that was mentioned in 2004, Lalonde, Lampron and Vanier, in 2008, studied the effectiveness of transitions programs on the risk of medication transition from inpatient to home. The risk of adverse drug reaction is actually quite high when a patient is discharged from the hospital. Approximately 10% of all patients experience some kind of adverse drug event. It is estimated that 42% of these events is preventable and a transitions program has been recommended. The purpose of this study was to determine how much a transitions program might affect the rate of medication discrepancies that happened between hospital and outpatient settings (Lalonde, et.al., 2004). The study was done in a pragmatic, open, randomized control trial. Medication discharge plans were designed for every patient in the group but only the random group in the study got the full transitions program in which there were many follow ups with patients as well as primary care providers. A total of 83 patients participated in the study. The result in this case ended in the fact that those patients who had a full transition program initiated had fewer adverse effects and fewer readmissions to the hospital. . Acute ischemic stroke is one of the diagnosis that has been noted to have great risk of recurrence as well as readmission to the hospital. Kind, and Smith (2007) studied this diagnosis in terms of a transitions program. Their objectives were to determine predictors as to whether the patients transition would be complicated and if so to get them into a transitions program. The study was done retrospectively and with administrative data. Four hundred and twenty two hospitals in the southern and eastern United States were included in the study. Thirty nine thousand three hundred and eighty four Medicare beneficiaries aged 65 and older discharged after acute ischemic stroke from 1998 to 2000 (Kind, et.al., 2007). Complicated transition was defined as movement from less to more intensive a program and that included home to hospital. Logistic regression was used to determine use of data. The conclusion showed that there were significant numbers of stroke patients that experienced complicated transitions and that those that the issues that were left for these patients could be solved with the development of a strong transitions program (Kind et.al., 2007). Each of these studies looked at a different aspect of the care transitions needs of patients. In each there was important information gained from the study itself. Different aspects of the same issue might combine these three studies into one care transitions program to assure decrease in patient risk, decrease admissions, and decrease adverse drug effects as well as the many other issue brought up by these researchers. These are just three of many studies noted that ended with a result of a care transitions program solving these issues in healthcare. Care Transitions Program Issue Plan Timeline Expected Outcome Collaboration with Directors directly involved such as the Director of case management Describe studies and backup information as well as plan, get opinions, ideas, and buy in from this important staff. Be sure to have buy in and final plan available by April 15th. Buy in to prevent future issues in implementation. Administrative approval PowerPoint presentation to administration including program staffing needs, ROI, documentation of studies done and results noted, and quality results for patients as well as staff. Presentation by April 22nd Reduction in risk to hospital and patients. Reduced length of stay. Reduction in readmission rate. Increased quality of care. Improved patient and staff satisfaction. Initiate Educational and training phase Education will need to be provided to caregivers on both ends of the process. That will include the case management staff in the hospital, the nursing staff on the units, the home health staff, skilled nursing staff, physicians, and pharmacists. This process will take time and much organization. However, teaching the case management staff first will allow for help in the rest of the teaching. The plan would be to teach one person in each of the contact institutions about the process to be used and allow them to teach their staff with provided materials. Initial training to begin May 1st. Complete training by June 1st. Assure that everyone that will be involved in the program understands how the program works so patients do not fall through the cracks. Begin the process with a single group of patients. To prevent causing major confusion with a new program that will affect so many, the plan would be to start with one diagnosis of patients and move on from there. In this case, the program would begin with stroke patients 65 or greater who have multiple medications. These patients would be part of the transitions care program throughout any transitions made from discharge from the hospital, starting with whichever of the other services were used. This part of the program would need to be followed for at least 6 months before expanding to the next diagnosis. Moving to the next phase would occur on Jan 1st 2011. Improved quality of care, better planning and less readmissions for this group of stroke victims. Next Phase The program will need to be expanded until patients in general that are discharged from the hospital with high risk for complicated transitions are covered by the program. However, for that to work well, it will have to be reevaluated at each phase to assure that the program remains on track and that research as well as staffing levels continue to keep up with the program. November 2010 will require a review of the research as well as staffing levels and policies to assure that this program is on track. January 2011 will begin the next phase. A continued improvement in the overall quality and efficacy of patient care both in the hospital and transitioned outside the hospital. In conclusion, the transitional care program first proposed by IOM, (2000) carried out by Medicaid to a lesser extent and studied by many seems to solve many of the issues of appropriate care, that is of better quality and decreased risk. However, it is also complicated to put into place and requires many people from many phases of care to participate and monitor. The main issue then becomes communication. Healthcare has had an issue for many years in which many of the different departments and levels of care work in silos. That will have to dissolve in order to make a true care transitions program work. It can be accomplished and studies show excellent outcomes but we have the system will have to become more connected for the good of the patients as well as the system. Resources Coleman, E. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous care needs. JAGS. 51. 549. Coleman, E., Smith, J., Frank, J. (2004). Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. JAGS. 52. 1817-1825. Coleman, E., Sung-joon, M., Chomiak, A. (2004). Posthospital care transitions: patterns, complications, and risk identification. Health Services Research 39:5. 1449-1465. Kind, A., Smith, M., Frytak, J. (2007). Bouncing back: patterns and predictors of complicated transitions 30 days after hospitalization for acute ischemic stroke. JAGS. 55. 365-373. Institute of Medicare Committee on Quality Healthcare. The State of Healthcare Quality. http://www.ncga.gov. LaLonde, L., Lampron, A., Vanier, M., (2008). Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings. American Journal of Health Systems Pharmacy. 65. 1451-1457. Magilvy,J. & Congdon, J. (2000). The crisis nature of health care transitions for rural older adults. Public Health Nursing. 17(5). 336-345. Stile, D., Jerout, B., (2005). Coordinating care across diseases, settings, an clinicians: a key role for the generalist in practice. Annals of Internal Medicine. Read More