Revision 5

Diabetes is a chronic condition affecting all age groups with individuals over 65 years at a higher risk (Butalia, 2020). One out of every five diabetic patients are readmitted back to the hospital within 30 days of discharge (Duke et al., 2013). Harkness (2020) reports that during transition of care, miscommunication between the providers and the ability of the new care facilities to meet the needs of patients may cause complications.

Transition of care (TOC) is the transfer of a patient from one care setting to another. We use the transition of care model when discharging a patient back to the community and is a complex process requiring the collaboration of case management and care coordination departments to ensure a safe discharge. Patients who move across care settings and experience high rates of post discharge complications, readmissions or morbidity and mortality benefit from TOC (Enderlin et al., 2012). Therefore, this Doctor of Nursing Practice (DNP) project will address readmission rates reduction for patients diagnosed with diabetes mellitus (DM) by using a TOC model in managed care. The project lead will focus on the use of the TOC model in the case management and care coordination departments of a managed care organization.

Background

Nine and three tenth percent of the American population, representing over 30 million people, live with DM, while 28% are undiagnosed (Duke et al., 2013). 25% of hospitalized patients are diabetic with a readmission rate of 14-22%, which is higher than the rate for all hospitalized patients that is estimated to be 8.5-13.5% (Rains, 2020). Patients diagnosed with DM are more likely than those without DM to be readmitted with other complications, such as heart failure, cardiac surgery, and myocardial infarction (Rubin, 2015).

Diabetes mellitus is a costly disease with direct medical cost of about $218 billion per year, besides indirect expenditure of $46 billion per year. Significant contributions to these expenditures are the readmission cases (Harkness, 2020). Studies associate lack of TOC protocol for diabetic patients with problems that hinder positive outcomes and increase readmission rates. Some challenges affecting this patient population include nonadherence to prescribed medications, lack of education on insulin injection, self-care measures, and healthy nutrition.

According to Garnica (2017), lack of discharge processes causes high readmission rates among diabetic patients. Often, there is inadequate coordination between the care provider and the caregiver at home. A lack of resources in the community setting, inability for the patient to manage self-care, and a low level of health literacy of the patient and the caregiver at home contribute to recidivism. Harkness (2020) notes that instances of poor care coordination can occur between the inpatient and outpatient settings when a patient discharges from the care facility to the community.

These events include lapses of communication between care providers in the inpatient and outpatient settings and include medication changes, diagnostic workups that are not done before the patient discharges, a lack of understanding of the diagnoses between the caregiver, patient and care provider, inadequate patient comprehension of medications, and insufficient coordination of the patients' follow-up needs at the time of discharge (Price, 2021). Therefore, it is necessary to create protocols using the TOC model as a framework to improve the transition process.

Creating a TOC protocol will guide the discharge process to ensure proper communication between the two settings (Duke et al., 2013). A well-formulated TOC protocol is a multidisciplinary approach to better understand discharge instructions and provide the resources needed for quality home care, thus reducing the readmission rate. The TOC model ensures that the patients' caregivers, informal support, and the home health agency caregivers in the community setting receive information regarding the patient's health status and the measures to guarantee proper care at home.

A patient is most vulnerable to adverse events when transitioning from the hospital to home (Harkness, 2020). Lack of care coordination and inadequate TOC protocols cost the healthcare system $46 billion a year (Harkness, 2020). Every year, DM patients' admission stay cost the United States $378 billion and readmission due to lack of TOC leads to an increase in the length of stay for patients in care settings, which further increases the financial burden. (Vandensande, 2020).

Problem Statement

There is a rising concern with readmission rates of DM patients. 14 percent of DM patients readmit within 30 days because of the lack of a TOC protocol to ensure that patients attain the health objectives set in the inpatient setting. Also, lack of adequate preparation before discharge leads to many patients returning to the healthcare facility because of various complications associated with DM (Rains, 2020).

Implementing an appropriate TOC protocol in the case management and care coordination department, which would address the gaps in the current interdisciplinary discharge process could prevent readmissions and associated costs (Shillington & McNeil, 2021). The project site does not use the TOC model framework in the discharge process, resulting in the duplication of services and missed responsibilities that have affected patients. It has also caused an increase in readmission rates within 30 days of discharge and has increased pressure for managed care organizations to improve care coordination (Grady et al., 2021). The project lead proposes implementing discharge protocols using the TOC framework to address these gaps in best practice to improve quality patient care.

Project Question

In case managers and care coordinators (P), how does the use of a TOC protocol (I) compared to the current practice without TOC protocol (C) reduce the readmission rates for patients diagnosed with DM (O) within 4-5 weeks (T)?

Search Methods

A systematic literature search of the academic databases was conducted including the PubMed, Web of Science, Overview (SCOPUS), and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) in Jay Sexter Library. These databases contain academic nursing research articles from peer-reviewed journals that are appropriate for clinical decision-making. They combine several search terms derived from the PICOT question. The search was refined by combining search terms and using the Boolean operator 'AND.' The resulting search phrases included "case managers transition of care and care quality 'care transition by coordinators' and 'self-care, DM, and DM self-care.

The initial search generated over 1000 results, but not all of them applied to this search technique. Then, the search was further refined by excluding articles published before 2016 to ensure this search only included recent scientific information relevant to modern patients with DM. Eligibility for inclusion consisted of full-text articles published in English. The exclusion criteria delineated any narrative review articles, editorials, monographs, abstracts, experience reports, dissertations.

These criteria reduced the search results to 113 articles, which were further appraised by reviewing the titles and abstracts. In reviewing the reference list of articles for any relevant information, 23 articles contained critical appraisal. The criteria gave three publications which extensively analyzed DM. Therefore, only the three publications from the Jay Sexter Library qualified to be included in the literature synthesis.

Review Synthesis

The search generated recent research articles (2016-2021) with scientific information relevant to modern patients with diabetes mellitus. Older articles could include outdated information that is irrelevant to current care settings. Combined, the articles showed the efficacy of TOC protocols by case managers and care coordinators in reducing readmission rates, improving self-care, and enhancing at-home quality care for patients with DM. Weber et al. (2017) conducted an integrative review focused on care transition between a patient's in-hospital stay and home care.

The authors concluded how important improving the organization of nurses and their activities are in managed care organizations to deliver better care coordination during the transition process. Weber et al. (2017) identified five themes after the comprehensive review, including planning for discharge, health education, coordination with other health care services, and follow-up after discharge. The study showed the need for further research on TOC to help implement integrated health systems. The study has also provided evidence that promoting care coordination in managed care discharge processes is important.

In a different study, Black and Duval (2019) found specific factors showing the quality of care is provided in managed care organizations. These indicators include preparing discharge care, education provided to patients and their families, continuity of care after discharge, and follow-up services. Elsewhere, Gallagher et al. (2017) focused on bridging administrative silos between various care management programs to improve the care and patient experience. The study identified various themes, including the process and communication in care provision, care transition, and patient experience. Patients with complex medical needs had a higher readmission rate. TOC reduced readmission rates for patients with diabetes and related complex medical conditions (Black & Duval, 2019).

Studies have revealed a gap in care coordination that affects care delivery, including lack of social services at the community level after discharge, little and reduced access to care within community settings, and poor communication. Poor communication between patients and care professionals after discharge influences outcomes. While in the community, the patients cannot access key information regarding their health because of lack of social services in the community. The healthcare service providers, such as doctors, cannot assess patients' progress after discharge since when the patient joins the community with no social services, it becomes difficult to trace them, and assess their progress. Multiple problems develop because of absence of transition of care protocols in managed care organizations (Black & Duval, 2019).

The high costs of healthcare services are greatly impacted by increased readmission rates (Black & Duval, 2019). Communication gaps between care providers and patients after discharge should be addressed to ensure proper care transition (Black & Duval, 2019).

Updating the transition of care protocols will ensure that care providers, care coordination, and case management departments collaborate in taking care of the DM patients. Therefore, patients diagnosed with DM could have sufficient access to fundamental services to break this cycle and reduce readmission rates and thus reduce healthcare costs (Gallagher et al., 2017).

Theme Development

Diabetes is a chronic condition associated with high readmission rates after discharge from a hospital to the community setting. Some factors, such as lack of TOC protocols and diabetes-related complications, cause high readmission rates. Transition of Care (TOC) protocols entail guidelines which dictate the movement of a patient from one care to another, and in this case, from hospital care to community care. These factors encompass absence discharge processes and poor quality of care while transitioning from the hospital to the community care setting. This can negatively affect the patient's finances, insurance and payment of services. Readmissions also increase when patients transfer to the community without adequate resources, such as caregiver education and community support systems (Brumm et al., 2016).

Communication

Communication lapses between care providers in inpatient and outpatient settings is devastating, yet a preventable problem. Miscommunication can cause misunderstandings regarding medication changes, diagnoses, and follow-up needs in community settings. The American Diabetes Association [ADA] (2020) has provided guidelines for patients being discharged from the hospital to the community setting.

The strategies from ADA guidelines include supportive clinical information systems, self-care management, and community resources and policies (ADA, 2020). Care transition is central to fulfill these ADA recommendations. Care providers are obligated to preserve the patients' safety and well-being as they transition to community care. Lack of transition of care protocols and care coordination can lead to potentially devastating patient outcomes and unnecessary healthcare spending (Shillington & McNeil, 2021).

Healthcare Costs

When patients readmit to the hospital, managed care organizations spend more resources to provide care. Care providers spend approximately 378 billion dollars every year because of patients' prolonged stay in managed care organizations (Shillington & McNeil, 2021). Such spending amplifies pressure on managed care organizations as they promote care coordination to enhance care delivery. Lately, lack of transition of care protocols has increased the number of DM patient's readmission, causing increased payment to providers. TOC model will help streamline healthcare delivery after discharge, which will lower readmission rates and hence lowering the costs of healthcare. The primary themes identified for the project include TOC for DM patients, discharge protocols in managed care organizations, a reduction of readmission rates, and collaboration between care coordination and case management departments.

Review of Study Methods

Twenty-six studies were identified, but only three studies were chosen for review. The three studies on transitions of care reviewed in the literature synthesis employed different research methodologies, a focused review (Black & Duval, 2019), integrative review (Weber et al., 2017), and descriptive longitudinal analysis (Gallagher et al., 2017). Each of these methodologies shows distinct strengths. The descriptive longitudinal analysis is a distinctive method allowing researchers to examine the same sample of participants over an extended period to determine any changes in outcomes (Caruana et al., 2015).

Researchers observe the effects of treatment without interfering with variables. This method enabled Gallagher et al. to examine a cohort of 17 patients who were readmitted to the hospital within 30 days of discharge. Most of the patients readmitted several times during the study period, which allowed the researchers to determine the factors contributing to high readmission rates relative to care transition. The descriptive longitudinal analysis design was appropriate for this study because Gallagher established the correlation between care transition protocols on readmission rates by examining the cohort multiple times.

In contrast, Weber et al. (2017) and Black and Duval (2019) conducted integrative reviews. Both review designs involve the systematic analysis of multiple research articles with heterogeneous methodologies to summarize underlying themes and conclusions. Integrative reviews generate reliable evidence because researchers can analyze many studies to establish gaps in literature, gauge the strength of literature, and show the need for additional research (Russell, 2005; Whittemore & Knafl, 2005).

Both focused and integrative reviews involve rigorous appraisal criteria of research articles to ensure the data included in the analysis are reliable and relevant. Results from such studies are more comprehensive and credible compared to data from a single descriptive study. The current literature synthesis incorporated evidence from research articles with reliable methodologies that show how TOC protocol promotes care quality for patients with DM.

Aims of the Project

The DNP project is a quality improvement program aimed at reducing readmission rates for patients diagnosed with diabetes to reduce health care costs for that population.

Project Objectives

The main objective is to design and implement a collaborative nursing transition protocol among case management care coordination departments period. The objectives for this DNP project will be completed within four to five weeks.

The objectives of this DNP project are:

a. To complete the transition of care protocol for patients diagnosed with diabetes being discharged from the acute setting to community setting.

b. To educate the providers on the new transition of care protocol.

c. To improve the knowledge and attitudes of the providers regarding transition of care of diabetic patients from acute to community setting.

d. To evaluate compliance of providers in utilizing the new protocol in practice within four to five weeks of implementation.

e. To evaluate readmission rates prior to project implementation, during project implementation and then one month after the implementation.

Theoretical Framework

Transition is defined as changes in lives, health, relationships, and environments (Garnica, 2017). During transitions, nurses’ step in and provide a therapeutic medium helping an individual have a smooth changeover from one care setting to another. The transition theory is significant to the process that occurs when a patient is going through changes in their lives and the nurses who provide help and guidance to achieve positive outcomes (Gill & Shanta, 2020). This theory is essential for the DNP project, which focuses on the transition of care for DM patients to reduce readmission rates and healthcare costs (see Appendix A).

Transition of Care protocols can decrease readmission of patients newly diagnosed with DM after they discharge from the hospital to community settings. The transition process exposes multiple risks to patients including a high possibility of readmission, poor outcomes, high care costs for patients and care providers related to readmissions (Black & Duval, 2019). Therefore, implementing TOC protocols will better meet the needs of patients diagnosed with DM by providing access to quality care and caregiver support during the transition between settings.

Historical Development

Nursing practice is guided by nursing theories, which describe phenomena and provide fundamental treatment principles. The transition theory that focuses on the nature of nursing practice is one of the most applied mid-range theories developed by the Egyptian theorist Afaf Ibrahim Meleis (Gill & Shanta, 2020). Meleis stated, that “nursing was always a part of her '' (Geary & Schumacher, 2019, pg number). She became the first individual in Egypt to obtain a Bachelor of Science in Nursing (BSN) degree from Syracuse University and then the first nurse to obtain a Master’s in Public Health (MPH) as well as a Doctor in Philosophy (Ph.D.) from the Egyptian University.

She moved to the United States (US) and pursued her graduate education as a Rockefeller Fellow. In 1964, she received her Master of Science (MS) in Nursing (MSN) from the University of California, Master of Arts (MA) in sociology in 1966, and Doctor of Philosophy (Ph.D) in medical and psychology in 1968 (Gill & Shanta, 2020). Meleis worked as an administrator and acting instructor at the University of California in Los Angeles as an assistant professor. She later went to the University of California in San Francisco, where she spent approximately 34 years, and this became the birthplace of the transition theory (Gill & Shanta, 2020).

Meleis focused her research on the transition process. The theory posits that nursing involves helping individuals going through changes that may either be physical such as illness or developmental, such as the birth of a child (Geary & Schumacher, 2019). Nurses provide primary care to patients and their families during transitions, where they attend to changes as well as the demands that are brought about by the process of transition (Harkness, 2020). Meleis investigated interventions aimed at ensuring a healthy transition. She associated an unhealthy transition with role inefficiency. The goal of healthy transition was defined as the mastery of behaviors, cues, sentiments, and symbols associated with roles and unproblematic processes (Gill & Shanta, 2020).

Tenets of Transition Theory

The middle-range theory of transition contains several major concepts: types and patterns of transitions, the properties of the transition experience, transition conditions, process indicators, and nursing therapeutics (Joly, 2016). Changes take various forms, such as developmental, health and illness, situational, and organizational (Kelly, 2014).

Patient Engagement

Patient engagement should be optimized through comprehensive and consistent efforts by the healthcare professionals to identify the outcomes of the given healthcare services, assess the patient's needs and capabilities, foster decision making concerning their plans, promote accountability for the shared care plans, and ensure trust and good relationship with the patients (Naylor et al., 2017).

Caregiver Engagement

The role of the caregiver is essential in the transition of care of diabetes patients. Healthcare professionals should engage the caregivers to ensure a smooth transition (Naylor et al., 2017). Here, identification of the most important outcomes of care to the caregiver is made. The caregiver’s capabilities and needs are assessed, fostering shared decision-making relating to the patient's care. The healthcare professionals should also ensure that shared accountability based on the care plans and the relationship with the caregivers is respectful (Naylor et al., 2017). The caregiver is given an important position in transition care, which will improve the outcome of the whole process of transition care.

Complexity Management

The complexity of management should be considered during the transition of care of diabetes patients (Naylor et al., 2017). It should be individually customized for the patients, holistic and consistent with the goals of the program. The challenge of management faced by the clinicians and the caregivers depends on the severity of the condition since it involves managing physical, emotional, and social needs (Naylor et al., 2017). By considering the complexity of the situation and identifying possible needs of the patient, it will be easy to address during the transition of care.

Patient Education

Patient Education should be a continuous and interactive process involving the health professionals and the patient (Naylor et al., 2017). This process is crucial because it ensures that the patient is aware that health is their responsibility, and hence it encourages the patient to make decisions towards a healthy lifestyle. Patient education also increases the patient’s adherence to medication and therapy, which promotes better health. It also reduces the adverse events resulting from the illness and promotes independence in the patient's daily living (Naylor et al., 2017). Here, the patient is given education about diabetes, the management options available, and healthy living.

Caregiver Education

Education of the caregiver also improves the care given to the patient once in the community. Caregivers should be taught different skills to identify and manage the worsening symptoms of diabetic patients on transition care (Naylor et al., 2017). The caregivers are also provided with access to community resources which supports the development of confidence and competencies essential in providing the patient’s needs and needs.

Well-Being of the Patient and the Caregiver

The wellness of the patient and the caregiver should be considered during the transition of care. The healthcare givers should acknowledge their skills. They should be respected and treated as human beings regardless of their emotional reactions, and their decisions that support the patient’s needs should be supported (Naylor et al., 2017).

Care Continuity

Individualized comprehensive care plans should be implemented (Naylor et al., 2017). These plans should ensure that there is access to appropriate, high-quality community patient care. The patient’s continuous access to comprehensive care fosters the health of the patient.

Accountability

The clinician and the whole team involved in the transition of care should assume the role of ensuring quality implementation of the transition of care (Naylor et al., 2017). There should be a partnership between clinicians and patients in developing patient care plans and ensuring their effective implementation. There should be teamwork among the different individuals involved, and there should be organizational accountability to ensure a conducive environment for the implementation of transition of care (Naylor et al., 2017).

Markedly, the DNP project focuses on the health and illness transition, including the diagnosis of diabetes, a chronic condition, the recovery process, and hospital discharge. The properties of the transition experience are not fundamentally disconnected, but they are interrelated as a complex process. These properties have sub-concepts such as awareness, engagement, change and difference, time and span, and critical points and events (Joly, 2016).

Awareness

The awareness sub-concept involves the perception, knowledge, and recognition of a patient on the transition experience. According to Kelly (2014), a patient in transition needs to be aware of the process and expectations. In the DNP project, DM patients need to be aware of their transition to experience, which helps identify a patient's readiness for care transition.

Engagement

Another property of transition is engagement, and this is defined as the involvement of a person in the transition process. The awareness of an individual on the transition process influences their level of engagement (Joly, 2016).

Change and differences

Changes and differences are properties of transitions, where changes that individuals experience during transitions generate a sense of movement from one setting of care to another. The differences are the challenging aspects that a patient has, including unsatisfied expectations or feeling dissimilar. Nurses must ensure that a patient's comfort level is sufficient to deal with the changes and differences during the transition of care.

Timespan

Timespan is a property of transition that involves movement over time (Joly, 2016). DM patients have an identifiable starting point of change that is often characterized by confusion, distress, and instability (Joly, 2016).

Critical points and events

Nurses should step in to alleviate these adverse effects of transition on patients. Critical points and events are markers, such as diagnosing a disease, and they are used to intensifying awareness of changes or boost engagement in the transition process (Joly, 2016). Case managers need to maximize care quality for DM patients as they undergo these critical markers.

The next concept is the transition condition, defined as circumstances and barriers influencing the movement of a person throughout the transition process (Garnica 2017). Common transition conditions include personal factors such as cultural beliefs and socioeconomic status, community factors like community resources available for the patient in the community setting, and societal factors such as marginalization of some communities (Garnica 2017). The theory cautions that the DM patients involved in the DNP project are also subject to these conditions. The fourth concept concerns indicators for a healthy transition process, classified into process indicators and outcome indicators (Joly, 2016). Process indicators help nurses assess DM patients and common risks to develop interventions that maximize positive outcomes. Outcome indicators help nurses to check if the transition is healthy or not (Garnica 2017). The last concept of the transition theory involves nursing therapeutics, which measure therapeutic interventions during the transition process.

Project Setting

The DNP project will take place in a Managed Care Organization located in the Southeast area of Dallas, Texas. The organization works with the Health and Human Services Commission (HHSC) of Texas to facilitate the patients in transitioning from the acute setting to the community setting. The organization has over 500 employees and serves more than 50,000 multiethnic Medicaid patients of all ages, however, the elderly population is the majority. Li et al. (2021) argues that there is a myriad of organizational issues in managed care settings that directly influence the high readmission rates among patients diagnosed with diabetes mellitus. Given the prevalence of readmission incidents, this an ideal setting for implementing this quality improvement project.

Electronic Health Records (EHR) are used for documentation by all departments and will be utilized for the project. QNXT is the name of the system the organization uses for documentation and for processing claims from which the high readmission rate report is pulled. The high readmission rate report shows cost and the readmission rate within 30 days of discharge from the acute setting and will be the main source of data for this project.

Population of Interest

The populations of interest for this project are the 45 care coordinators (CC) and 15 case managers (CM) who are nurses. On average, these nurses have worked in their respective departments for seven years, so they are familiar with organization’s current policies, procedures, and workflows. They are included in this project because their work directly impacts the TOC outcome. The case managers are responsible for completing post-hospital assessments to identify patients’ needs, while the care coordinators focus on coordinating care with other community providers to ensure identified needs are addressed. These nurses will be educated in the new protocol regarding discharges and community transitions to reduce readmission rates.

Patients diagnosed with DM will be the indirect population for this project as they are the primary beneficiaries of the intervention. According to Rains (2020), 25% of hospitalized patients have diabetes, with a readmission rate of 14-22%, which is higher than all hospitalized patients and estimated to be 8.5-13.5%. Rubin (2015) further adds that patients diagnosed with DM are more likely than those patients without DM to be readmitted with other complications, such as heart failure, cardiac surgery, and myocardial infarction. In this regard, the project was designed to positively impact this patient population indirectly by improving TOC practices. In addition, nurses from other departments, those who are on leave of absence (LOA), and all administrative staff will be excluded from the project.

Stakeholders

Considering the nature of the project, the full support of the organizational leadership is required. Their primary roles are to provide approvals for carrying out the project within the organization, managing the existing human resources, and providing social support to the DNP student and nurses in order to ensure the successful completion of the project. Edwards et al. (2019) stated the administration team forms the backbone of a quality improvement approach as they provide a purpose for unity while at the same time outlining the direction for the organization.

Case management and care coordination managers, utilization management director, and the vice president (VP) of operations play vital roles in the success of this project. The VP granted permission in writing to conduct the project at the project site (see Appendix B), the directors identified subject matter within their departments and the case management and care coordination managers mobilized nurses to participate in the project. Similarly, the utilization management team will provide the needed data such as a readmission report for identification of diabetic patients with readmission to acute setting in less than 30 days after discharge. The project lead will also obtain a utilization report that shows the financial impact of patient readmission within 30 days. Meetings will be held routinely with the utilization management leadership and managers of the CC and CM departments to attain support and feedback. Relevant communications regarding project topic will enhance buy-in and relationship building between the project lead and stakeholders.

The nursing staff represents another set of stakeholders in this DNP project. They are the individuals who have direct contact with patients and will be implementing the protocol. Finally, patients diagnosed with DM will be the beneficiaries of the positive outcome of the project and are the indirect stakeholders.

Intervention

This quality improvement intervention involves training and educating the care coordinators and case managers on the use of TOC protocol to reduce readmission rates for diabetic patients as they transition from acute to the community setting. The transition protocol needs to be comprehensive, and it is more efficient when the interventions are individualized to meet every patient’s needs (Garnica 2017). A detailed intervention timeline has been provided below Comment by Denise Zabriskie: Training and educating are the same

Week 1 Comment by Denise Zabriskie [2]: Please follow APA format for your headings

The project lead will collect pre-implementation data going back one month to include the readmission reports of diabetic patients, readmitted to the acute care setting within 30 days of discharge. A pretest questionnaire will be administered for the case managers and the care coordinators to test their knowledge in transition of care. A three-day staff training will be conducted in two-hour sessions. A post-test will also be administered immediately after training; the with an overall pass grade is 80 percent. A group remediation will also be conducted for staff members with less than the pass grade. The data collected will be input into an SPSS software version 17.0 Comment by Tracey Barsey: From one month prior, to include…. Comment by Denise Zabriskie: The education is going to take three days to complete? Comment by Tracey Barsey: A passing grade.

Week 2-4

The TOC protocol will be implemented, and the project lead will be on the premises to offer support, answer questions and ensure compliance among the case managers and the care coordinators. At the beginning of week three a retrospective chart audit will be conducted to look at week two by utilizing an audit tool to evaluate provider compliance with the protocol. The audit tool will be used to identify to evaluate to determine any gaps with the TOC, if any gaps are identified, then they will be addressed by connecting with the community providers involved such as the pharmacist transport companies and home health agencies. Comment by Tracey Barsey: collaborating

Week 5

The project success will be measured by comparing the readmission rates of DM patients for four weeks during the implementation of the TOC protocol and the readmission rates four-weeks prior to the implementation. At the end of the week all the results from the implementation phase will be analyzed using the SPSS program and stored in an excel spreadsheet. Comment by Tracey Barsey: all of the results

Tools

The tools that will be used are existing and new ones will be developed by the project lead. The intervention will also utilize some managed care resources to ensure that the transition is well executed. The TOC protocol will be established and validated in consultation with experts. The tools include

Pre and Post Test

The pre and post-test tool will be used to gauge the participants attitude and knowledge of the TOC for diabetic patients. (see Appendix C) This tool was developed by the project lead and will be utilized in assessing the diabetic knowledge of the care coordinators and case management. There are ten multiple choice questions on the test. Participants’ will be expected to score 80% and above to pass the post test. A group remediation will be done for providers that score below 80%. Multiple choice questions are an efficient and effective way to evaluate learning objectives (Brame, 2013). Comment by Denise Zabriskie: Brame, C. (2013) Writing good multiple choice test questions. Retrieved [todaysdate] from https://cft.vanderbilt.edu/guides-sub-pages/writing-good-multiple-choice-test-questions/

The Transition of Care Protocol

The TOC protocol was developed by the project lead; it is a step by step instructions on what the process is to care for a diabetic patient after discharge from acute to community setting.( see Appendix D). The tool will be validated by expert consultation through stakeholders. The project team will also be consulted for validation. Post-validation, the project lead will obtain approval from organizational leadership to utilize the protocol. The protocol is broken down into four parts A to D. Part A “Patient discharges from acute setting to the community” explains the responsibility of the case manager and care coordinator up to 72 hours after patient’s discharge from acute setting. Parts B and C covers step by step instructions for case managers and care coordinator during the Post Discharge Assessment (PDA) call or visit and first thirty-days after discharge respectively. Lastly, Part D explains what is expected of the care coordinator after days of discharge. Comment by Tracey Barsey: How many days or weeks?

 This tool is a guide for provider documentation. It is also used to gauge compliance with the transition of care protocol. The tool was developed by the American Pediatric Association for use in transition of care protocols as a guide to determine patient’s readiness for care transition (Little et al., 2017). The tool is readily available and does not need permission for its use. Provider assessment will also gauge the care provider performance and in identification of gaps that need to be addressed for a more effective transition (BSTB, n.d.). The project lead will use this tool when performing chart audits to make sure they were utilized and completed systematically.  Comment by Denise Zabriskie [2]: Is this a guide or instructions? How is it going to guage compliance? Comment by Tracey Barsey: Will you monitor compliance by looking for the tool during chart audits? Comment by Denise Zabriskie: Please clarify. I don’t understand this sentence

The project lead provides accountability to the management of the organization using the assessment template and will obtain authorization to implement the tool from the organizational management. 

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Educational Presentation

PowerPoint presentations will be the main training tool. It will be created by the project lead and validated by expert consultation through stakeholders with project team consultations.   Comment by Tracey Barsey: Suggestion: validated by content experts, stakeholders and project team consults. Comment by Denise Zabriskie: Please elaborate what information will be provided in the power point presentations.

Chart Audit Tool Comment by Denise Zabriskie: Your chart audit tool will be a copy of the assessment template, which contains the required protocol documentation. If the assessment template is partially completed then it is considered a non-compliant chart.

References