Literature and 10 Strategic Points, Grand Canyon Un\iversity

The 10 Strategic Points

Title of Project

1) Title of Project

Implementing AHRQ Re-Engineered Discharge Toolkit Phone Call to Reduce 30 days Readmission

Background

Theoretical Foundation

Literature Synthesis

Practice Change Recommendation

2) Background to Chosen Evidence-Based Intervention:

i) Background of the Practice/gap at the project site

· Heart failure impact approximately 6.2 million adults in the United States and has an estimated cost of $30.7 billion ever year in care nationally (Rizzuto et al., 2022).

· Self-care deficit and non-compliance with treatment are the most common reasons for patient readmission to SNF.

· SNF in rural NJ has seen approximately 120 readmissions over the period of 6 months with adult patients with Heart Failure.

· Weekly approximately 10 patients are discharging home from SNF and returned within a 30-day period.

· Educating nurses in the sub-acute setting on how to conduct a follow-up phone call using AHRQ (2020), Re-Engineer Discharge follow-up phone call to ensure compliance with treatment can potentially reduce 30-days readmission.

· AHRQ Re-Engineered Discharge Follow-up phone call increases patient education and compliance with care, early symptom recognition, lifestyle medication, adhere to medication and follow-up appointments can result in a reduction in readmission rates (Du et al., 2020).

· Therefore, using tools like the AHRQ Re-Engineered Discharge (RED) toolkit, follow-up phone call Step #5 is one way to improve compliance with care in patients with heart failure to reduce readmission rates (AHRQ, 2020).

ii) Significance of the practice problem/gap at the project site

At this time, the AHRQ, RED toolkit follow-up phone call step #5 is not being used at the DPI project site. Currently, a care conference is planned involving the family caregiver who will assist the patient at home, but there is no focus on follow-up phone call. This has led to the same patients being admitted within a 30-day period. According to Deek et al. (2017), involving family caregivers in the self-care of heart failure patients is helpful to maintain compliance in care. On discharge patients and family are given verbal and written discharge instructions on how to reduce exacerbation of Heart Failure symptoms.

iii) Theoretical Foundations

· Orem’s Theory on Self-Care Deficit will guide the implementation of AHRQ Re-engineer Discharge Follow-up Phone Call Toolkit # 5 to address the self-care deficit in improving the patient’s health outcomes with and advanced nurses’ help (Orem, 1971).

· This theory focuses on Self-care deficit to improve patients’ health outcomes (Orem, 1971).

· This theory involves improving patient’s health outcomes with the nurses’ help. Therefore, the nurse makes the necessary interventions to help the patient achieve their self-care needs (Orem, 1971).

· So, Orem's theory of self-care deficit evidence-based interventions is a good way to decrease patients’ non-compliance with care and increase patient’s self-management confidence and emotional well-being and increases the nurse’s job satisfaction and engagement (Orem, 1971).

· Implementation of the Re-Engineered Discharge follow-up phone call will help patients maintain compliance. It will also determine patient understanding of Heart Failure care and symptoms to achieve optimal health outcomes to reduce readmission.

· Rogers’ Diffusion of Innovation (DOI) theory states “knowledge is produced when an individual is exposed to an existing innovation and acquires some understanding about the mechanism and functions” (Rogers, 1962).

· Rogers’ diffusion of innovations theory shows how ideas become embedded within a setting by using social system, time, means of communication and the proposed new idea as an important component of the theory to implement change (Rogers, 1962).

· Innovation diffusion is conceived as occurring over a number of stages, including knowledge, persuasion, decision-making, execution, and confirmation.

· According to this idea, there are five groups of change-adopters: innovators, early adopters, early majority, late majority, and lastly the laggards, who are dispersed along a bell-curve (Rogers, 1962).

· The use of bedside nurses in the sub-acute setting to help in data collection will promote knowledge of the need to help reduce readmissions rates in heart failure patients by using the AHRQ Re-Engineered follow up phone call toolkit #5 to reduce re-admission rates.

· This DPI project will translate the evidence into practice for this particular site.

iv) Annotated Bibliography

Deek, H., Chang, S., Newton, P. J. Noureddine, S., Inglis, S. C., Arab, G. A., Kabbani, S., Chalak, W., Timani, N., MacDonald, P. S., & Davidson, P. M. (2017). An evaluation of involving family caregivers in the self-care of heart failure patients on hospital readmission: Randomised controlled trial (the Family study). International Journal of Nursing Studies, 75, 101-11. https://doi.org.lopes.idm.oclc.org/10.1016/j.jnurstu.2017.07.015

This randomized trial is an evaluation of involving family caregivers in the self-care of heart failure patients on hospital readmission. The study was conducted over a 13-month period in three tertiary medical centers in Beirut and Mount Lebanon, Lebanon. 256 patients. The study was conducted over a 13-month period in three tertiary medical centers in Beirut and Mount Lebanon, Lebanon.

Follow-up phone calls were conducted 30 days following discharge. Method can be used in the DPI project. Data were analyzed using version 22 of the Statistical Product and Service Solutions (SPSS)

Follow-up phone calls were conducted 30 days following discharge Data were analyzed using version 22 of the Statistical Product and Service Solutions (SPSS). It was show that readmission at 30 days was significantly lower in the intervention group compared to the control group (n = 10, 9% vs. n = 20, 19% respectively, OR = 0.40, 95% CI = 0.02, 0.10, p = 0.02). In terms of the primary outcome, this novel self-care promotion intervention resulted in a significant reduction in the 30-day readmission incidence among these .

Yiadom, M. Y. A. B., Domenico, H., Byrne, D., Hasselblad, M. M., Gatto, C. L., Kripalani, S., Choma, N., Tucker, S., Wang, L., Bhatia, M. C., Morrison, J., Harrell, F. E., Hartert, T., & Bernard, G. (2018). Randomized controlled pragmatic clinical trial evaluating the effectiveness of a discharge follow-up phone call on 30-day hospital readmissions: balancing pragmatic and explanatory design considerations. BMJ open, 8(2), e019600. https://doi.org/10.1136/bmjopen-2017-019600

v) Practice Change Recommendation: Validation of the Chosen Evidence-Based Intervention

Agency for Healthcare Research and Quality (2020), validates the use of the Re-Engineered Discharge (RED)Toolkit. Re-Engineered Discharge (RED) Toolkit to conduct a Post discharge Follow-up Telephone Call and how it impacts 30 days readmission rates. According to AHRQ (2020), These results have important implications for quality of care and costs for the more than 38 million patient discharges each year in the United States. Patients who received the RED experienced a 30 percent lower rate of readmission within 30 days of discharge compared to patients receiving usual care. Readmitted patients who received post-discharge follow-up calls had significant improvements in the length of time after dikscharge. Future development could include developing additional call strategies (Mwachiro, Baron & Kates, 2019). The education materials and toolkit from the AHRQ will teach nurses how to conduct the follow phone to provide quality care to heart failure patients.

vi) Summary of the Findings written in this section

This annotated biography includes research that proves the Re-Engineered Discharge (RED) follow-up phone call Toolkit #5 is reliable and can be used for Direct Project Improvement at the chosen site. Over a 30-day period, RED has been shown to lower the number of times people with heart failure have to be readmitted. The goal of the Re-Engineered Discharge (RED) is to better prepare patients and their families for leaving the SNF, make patients and their families happier, and lower the number of times people have to go back to be readmitted (AHRQ, 2020). The post-discharge follow-up phone call, RED, is an important way to help the patient from the time they are sent home until their first appointment for follow-up care (AHRQ, 2020).

Problem Statement

3) Problem Statement:

It is not known if the implementation of Agency for Healthcare Research & Quality (AHRQ) guidelines, Re-Engineered discharge follow up phone call toolkit #5 would impact 30-day readmission rates when compared to current practices among Adult Heart Failure Patients.

PICOT to Evidence-Based Question

4) PICOT Question Converts to Evidence-Based Question:

Evidence-Based Question

In adult patients with Heart Failure in the skilled nursing setting does the Agency for Healthcare Research and Quality’s (AHRQ) Re-Engineered Discharge (RED) toolkit, follow up phone call step #5 compared to current practices impact 30 days readmission rates over a period of 8 weeks?

Sample

Setting

Location

Inclusion and Exclusion Criteria

5) Sample, Setting, Location

i) Sample and Sample Size: To determine the sample size, a sample size calculator, UCSF clinical & Translational Science Institute’s sample size calculator is used to find out the amount of patient to use in this DPI project. This Skilled Nursing Facility sees approximately 50 patients on a weekly basis with diagnosis of Heart Failure, Patient are sent from the local hospital telemetry department to the sub-acute unit. With a confidence level of 95% and a confidence interval of 10, a sample size of 37 will be needed for this project. There should be no bias and all participants will be included in the study and the sample size. This unit has 100 beds and we see approximately 50 patients weekly. All adult patients with Heart Failure will be qualified as a candidate for this project. This unit has a cardiovascular program, because of the number of patients admitted with cardiovascular disease. The sample size will be provided close to the implementation of the project.

ii) Setting: Skilled Nursing Facility

iii) Location: Rural New Jersey

iv) Inclusion Criteria

Who can participate?

· All adults with Heart Failure

· Patients awake, alert, oriented x4

· Who speaks English

· Patients admitted for Short Term Stay

· Patients who are not willing to participate

v) Exclusion Criteria

Who cannot Participate

· Long Term Care Patients

· Patients under 20 years old

· Patients who are not awake, alert, orientedx4

· Cannot speak English

· Patients who are not willing to participate

Define Variables

6) Define Variables:

i) Independent Variable (Intervention): Agency for Healthcare Research and Quality (AHRQ) using the Re-Engineered Discharge (RED) Toolkit #5 follow-up phone call.

ii) Dependent Variable (Measurable patient outcome): Readmission rates pre and post intervention.

Project Design

7) Project Design:

i) This quality improvement project will use a quantitative methodology with a quasi-experimental design, as the effectiveness of AHRQ Re-Engineer Discharge follow-up Phone call to reduce 30-days readmission rates in adult Heart Failure patients.

ii) For this DPI project, we will use information from past research on the Re-Engineered Discharge (RED) follow-up Phone Call Toolkit #5 to show decrease in readmission rates in patients with Heart Failure. This project will use a quantitative method of quasi experimental design. The Quality Improvement (QI) will focus on system issue of patient comprehension how to take care of themselves after discharge with methods that are clear and easily understood. Along with this, nurses will place follow-up phone calls to reinforce, remind patients and clarify misunderstanding on how to maintain compliance with treatment. Data will be collected on current follow up phone call practices, implementation of new methods, and monitor data on the new method to ensure patients understands, and a quality outcome should be reduction in readmission rates.

Purpose Statement

8) Purpose Statement:

The purpose of this quality improvement project is to determine if the implementation of AHRQ guidelines, re-engineered discharge follow up phone call toolkit#5 would impact 30-day readmission rates when compared to current practices among adult heart failure patients. This project was piloted over an eight-week period in rural New Jersey skilled nursing facility.

Data Collection Approach

9) Data Collection Approach:

i) We will use an excel spreadsheet to gather data on demographics which includes, age, race, ethnicity, diagnosis and readmission rates from Electronic Health Record (EHR). Using the patient health care information from the EHR to access data with permission from the project site. The data included will be comparative and implementation data on patients, comparative and implementation data on the number of patients that needs a follow-up call after discharge.

ii) There will be a standard discharge instruction and also a patient specific instruction on self-care and compliance. It is necessary to document how many follow-ups phone calls each patient will receive and how much info each nurse has completed for each patient. The facility’s Electronic Health Record (EHR) will be used when necessary to gather data related to heart failure patients, their care plans, goals, and intervention implemented by the team during the duration of the project. More data collection will be completed to verify the number of patients with Heart Failure who were compliant after receiving follow-up phone calls and the impact it had on the readmission rates compared to current practices.

iii) The tools have been tested many times among various agencies and even translated into diverse languages.

iv) Describe the step-by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants.

(1) Discuss how I am going to complete this project implementation and collect data on the measurable outcome.

(2) The need for the necessity of an IRB will be decided. For this project, IRB process will begin with Grand Canyon University (GCU) as the clinical agency as the project site does not have an IRB. After approval from the IRB is received, there will be a teaching session to educate the nurses and other staff wo are included in the project. Then participants who met the criteria will be given the implementation plan.

(3) For the sample size that is available at the time of the project, will, they will be given the opportunity to change their minds and opt out if necessary. There will be no direct contact between the participants and the project leader.

(4) Patient teaching will be reinforced focusing on understanding treatment goals. This will be done on each follow-up phone call.

(5) On completion of the project with the 8-week period, nurses will re-educate the patients and allow them to acknowledge understanding.

(6) The appropriate personnel will be given a report with referral for further recommendations.

v) In quality improvement projects, the upholding of ethical concepts such as autonomy, beneficence, non-maleficence, and fairness ought to be held to the same exacting standards as those required in clinical research (Hall, Lee & Haase, 2020). Participants in QI projects may be exposed to risk or burden, computer screens, or conversations that take place in hallways or elevators, regardless of whether this was done intentionally or not. Generally speaking, quality improvement programs are subjected to some level of internal assessment in order to reduce the risk to participants and ensure participant confidentiality. During this DPI project we will maintain respect of the decisions made by participants ensuring they are not harmed in way or form. All participants will be treated fairly.

Data Analysis Approach

10) Data Analysis Approach:

· An a priori analysis will be used to justify the sample. As mentioned above UCSF clinical & Translational Science Institute’s sample size calculator was used to calculate a sample size of 37 participants

· A summary of Descriptive Statistic of participants frequency related to demographics and participation of candidates. The inclusion of engagement and grasping knowledge of the procedures outlined and acknowledgement of competencies.

· The uses of paired t- test will be utilized to find the difference in the two data from one participant. This is not yet determined. There is validity in using this tool. A statistician may be used. Discuss bias and mitigation. V