NURS FPX 6614 Assessment 1: Defining a Gap in Practice

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Defining a Gap in Practice: Executive Summary

A practice gap has been identified in the re-hospitalization of older adults after 30 days of discharge. A cohort study of 2698 older adults discharged from the geriatric units of the hospital between May 2015 and May 2020 revealed a readmission rate of 5.18%. It is worth noting that Samuel et al. (2022) showed that 41.4% of these readmissions are preventable. As a rule, the re-admittance took ten days. NURS FPX 6614 Assessment 1: Defining a Gap in Practice: The high rate of avoidable readmissions indicates a lack of collaboration between transitional care and ongoing care for elderly patients post-discharge. Poor planning for discharge, inadequate patient teaching and training, late follow-up of outpatients, and non-provision of support for medications and other needs of the patients post-discharge would be major contributing factors (Samuel et al., 2022).

Clinical Priorities with Care Coordination Process

In order to enhance the care management and outcomes of older adults with co-morbidities, special clinical areas serving their multiple needs should be the main focus. This population is prone to drug problems, falls, and confusion, and strict drug control becomes a leading issue. This also should involve drug adjustment and patient education after discharge from the hospital. The provision of structured release planning, explicit care instructions, and follow-up appointments, among other things, is also essential to prevent care gaps and subsequent readmissions. Referrals to home care services, visiting nurses, and follow-up appointments with the primary care provider can assist people in maintaining control of their health, thus preventing them from deteriorating or debilitating. NURS FPX 6614 Assessment 1: Defining a Gap in Practice: To keep the care plan consistent, the care coordination should improve communication between patients, people in the hospital, and those in the post-acute settings (Yoon et al., 2019).

Another fundamental category is the mobility of elderly people and the prevention of injury so that the aged may continue to function physiologically. This should be included in the hospital discharge protocols so that the patients can be mobilized as early as possible, outpatient physiotherapy reviews, and home safety checks post-hospital discharge. Pain, cognitive disability, mental health, diet, and access to transportation are some of the other clinical goals to be managed for these patients with their complicated needs, prevent things from going bad, and assist them to recover and become independent. A co-ordinated, patient-centred approach to these clinical priority areas, which engages multidisciplinary teams across different settings, can lead to better outcomes for the most vulnerable older people (Daly et al., 2019).

Information Gaps

High readmission rates mean that there is an issue with transitional care management of the elderly who are discharged from the hospital. Nevertheless, a lot of research is still necessary to comprehend this issue. The exact factors that lead to avoidable readmissions of this group remain a critical knowledge gap. By considering different situations, such as comparing return rates between units in a hospital or between two groups of people, the fact that care processes are not always alike could be revealed. Interviewing more patients and caregivers might be useful to gain their perspective and look at how care changes throughout the entire illness episode. NURS FPX 6614 Assessment 1: Defining a Gap in Practice: A clearer understanding of why actions must be taken to improve care coordination and to reduce avoidable readmissions in this high-risk group can be achieved by finding information gaps, exploring alternative hypotheses and scenarios, and collecting and analyzing more data (Hestevik et al., 2019).

PICOT Question

For older people aged 65 and up who have been removed from the hospital (P), how does a nurse-led transitional care intervention (I) compare to normal release planning (C) in terms of 30-day hospital return rates (O) over six months (T)?
Population: 65 years and older adults who were released from the hospital
Intervention: A nurse-led transitional care solution is put into place.
Comparison: Typical plans for discharge
Outcomes: change the number of 30-day hospital readmissions
Time: Six months of time
The Gap in Practice

A big gap in the provision of temporary care for those who are 65 and over has been found by the hospital.The return rate within 30 days for this group is 18% as compared to the 15% that was the national average (Oliver et al., 2022). Medications issues, infections, and falls are the principal reasons why this population needs to be readmitted. Many of these outcomes might have been prevented by better moving care.

Need for Change

The gaps in care management, release planning, patient instruction, and follow-up care after hospital discharge are apparent in the fact that elderly patients are readmitted to hospitals a lot more than they should be. The majority of the studies that employ evidence-based evidence indicate that organization between hospital, home health, and primary care in transitional care measures helps achieve significant reductions in readmissions. It is equally a national goal and a strong recommendation within the clinical practice standards to enhance the transfer of care of the elderly. Improved transitioning care will lead to better care of the patients, and avoidable readmissions will be reduced; hence, the healthcare costs will go down. NURS FPX 6614 Assessment 1: Defining a Gap in Practice: One of the successful methods is the nurse-led transitional care model, which is in line with the ambitious goals of this hospital, which is to improve care management during the whole care continuum (Kripalani et al., 2019).

Potential Services and Resources

The local health system has some services and tools that may be utilized in order to improve the coordination of the elderly when they are being discharged from the hospital to their homes. At the health system, the Aging Well outpatient facility provides comprehensive assessment and care management for the elderly, which could simplify communication after they are discharged to avoid readmission to the hospital. One possibility is to add more live care managers that can operate in this clinic. Home health nursing services in the system are also available that can carry out evaluations, care, and care management in people’s own homes. The continuity of care plan is enhanced when hospital discharge managers and home health nurses collaborate more (Shepperd et al., 2021).

Policies at the state and national level emphasize the need for care coordination across settings in transitional care and avoidable readmissions. The Reducing Preventable Readmissions program of the State Department of Health provides the health systems with transitional care models that are evidence-based. It achieves this by paying them money and other assets. Participating in this project would help in creating a nurse-led transitional care program. The government Hospital Readmissions Reduction Program is a reward and punishment system which punishes hospitals that have too many readmissions and rewards those that make changes. Compliance with national regulations is another reason for closing the gaps in transitional care for older people (Joynt Maddox et al., 2019).

Barriers and Analysis

Logistical issues involve patient tracking as they travel from one place to the other, accessing their data, and handoff planning. At a patient level, barriers to smooth transfer will include limited health literacy or self-management, a lack of family or social support, and the challenges of adherence to release plans due to cognitive impairment or mental health. To improve the quality of transitional care for the elderly, these issues should be handled carefully, participation of the key parties should be called for, policy changes should be proposed, and established processes should be in place (Wadhera et al., 2021).

Care Coordination Intervention

There is a lot of evidence in support of a transitional care plan managed by advanced practice nurses to provide better coordination of care and to reduce avoidable readmissions for high-risk older people. The transitional care plan that has been examined and found to be most effective is the Care Transitions Intervention (CTI) for this population (Jacobsohn et al., 2021). One of the important components of CTI is the employment of a Transitional Care Nurse (TCN), who provides direct patient teaching, medication reconciliation, discharge planning, and follow-up for 30 days post-hospitalization. The researchers, utilizing a number of randomized controlled studies, found that CTI is more effective in reducing 30-day readmissions as well as improving patient satisfaction over usual care (Earl et al., 2020).

CTI is a great match for this health system in a variety of aspects. It implements care planning activities that have been proven to reduce the rate of readmissions. The TCN position also aligns with our organizational aim of providing more nursing care management services all along the continuum. Most of the nurses in our hospital who are master’s degree holders would make excellent TCNs with a slight additional training. Despite the upfront cost, CTI has proven to be cost-effective in the long run by reducing unnecessary use. The best way to enhance the quality and management of transitional care for the elderly is by using a research-based transitional care plan like CTI (Earl et al., 2020).

Addressing the Care Coordination Intervention

To put CTI into action, you need to get support from the top of the organization, train nurses for the job of Transitional Care Nurse, formalize processes and standards, set criteria for identifying patients, assign resources, and plan evaluation measures. Getting early support from key stakeholders will make it easier to get resources and system changes approved (Shah et al., 2022). Putting a group of nurses through the well-known 3-day CTI training program will help them get better at rechecking patients’ medications, teaching them about warning signs, and talking to outpatient providers. Lastly, to measure the success of the program, things like 30-day readmissions, ED visits, and patient happiness should be set up. Planning and getting ready ahead of time will help make CTI work better and last longer to close the transitional care gap (Conner et al., 2021).

Nursing Diagnosis for Collaborative Care

To give an example of enrollment and the nursing diagnosis for the support of transitional care, NANDA International describes this type of condition as one of the greatest problems for nursing. This gave a clue on the implementation of the care plan with the release date reminding the person to engage in the planning, move through the problems they have, and to know about their care needs once out of the hospital. It is used mainly by the elders, who often need to be provided with more organized management or more unified caregiving as they age.

Proposed Care Coordination Strategy

Here, the CTI or Care Transitions Intervention could be utilized as a form of treatment to handle this problem. Here, the care management model is based on data. Transitional Nurse provides patients and their families comprehensive education in the hospital, and they assist in planning discharge and follow up with them at home for 30 days after discharge. NURS FPX 6614 Assessment 1: Defining a Gap in Practice: From this program, patients and their families are enabled to make a shift towards self-care by using these core CTI components: medication adherence, patient coaching, structured hand-off, and total involvement of patients and their kin. Research shows that hospitalizations can be reduced significantly, and so can readmissions within the thirty days of transition (Kooyman & Witry, 2019). Further, these interventions improve the continuity and quality of the care transition.