Literature and 10 Strategic Points, Grand Canyon Un\iversity

The 10 Strategic Points

Title of Project

1) Title of Project

Implementation of a Follow-Up Discharge Phone Call to Impact 30 days Readmission Rates Comment by Ginger King: I changed up your title.

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 the 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 (Yip, 2021). Comment by Ginger King: Please use the seminal (original) source. I believe this was 1971. Please replace this article by Yip. It doesn’t belong here.

· This theory focuses on Self-care deficit to improve patients’ health outcomes Parker & Hill, 2017). Comment by Ginger King: Replace this with the seminal source.

· 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 (Yip, 2021).

· 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(Yip, 2021).

· 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” (Mohammed et al., 2018, p.26). Comment by Ginger King: There are many formatting issues that you will need to address. Please make sure to discuss this is a change theory. Also you need to use the seminal source which I believe is 1962. Please remove the other articles (like Mohammed et al). They don’t belong here.

· 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 (Friesen et al., 2017).

· 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 (Rizan et al., 2017).

· 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

Lynggaard, V., Zwisler, A. D., Taylor, R. S., May, O., & Nielsen, C. V. (2020). Effects of the patient education strategy “Learning and Coping” in cardiac rehabilitation on readmissions and mortality: a randomized controlled trial (LC-REHAB). Health Education Research, 35(1), 74–85. https://doi-org.lopes.idm.oclc.org/10.1093/her/cyz034 Comment by Ginger King: This does not open the full article. You have to pay for this article. However, your five original primary research articles must align with your problem, purpose, and evidence based question and support the intervention. These five articles should directly relate to the intervention. This article (based on the abstract) does not relate to your intervention. Please replace the article.

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 seriously affected patients. Comment by Ginger King: Please write your data in the correct statistical formatting.

Boxer, R. S., Dolansky, M. A., Chaussee, E. L., Campbell, J. D., Daddato, A. E., Page, R. L., 2nd, Fairclough, D. L., & Gravenstein, S. (2022). A Randomized Controlled Trial of Heart Failure Disease Management in Skilled Nursing Facilities. Journal of the American Medical Directors Association, 23(3), 359–366. https://doi.org/10.1016/j.jamda.2021.05.023 Comment by Ginger King: This does not open the full article. You have to pay for this article. However, your five original primary research articles must align with your problem, purpose, and evidence based question and support the intervention. These five articles should directly relate to the intervention. This article (based on the abstract) does not relate to your intervention. I don’t see anything about a discharge phone call in this abstract. Please replace the article.

The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF. The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care) in the INTERACT quality improvement program. This program included tools designed to improve the identification, evaluation, management, communication, and documentation of acute changes in condition in SNFs. The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome. Comment by Ginger King: Please provide statistical data. At least the p value.

Weerahandi, H., Chaussee, E. L., Dodson, J. A., Dolansky, M., & Boxer, R. S. (2022). Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients with a Primary Diagnosis of Heart Failure. Journal of the American Medical Directors Association, 23(3), 367–372. https://doi.org/10.1016/j.jamda.2021.08.002 Comment by Ginger King: This does not open the full article. You have to pay for this article. However, your five original primary research articles must align with your problem, purpose, and evidence based question and support the intervention. These five articles should directly relate to the intervention. This article (based on the abstract) does not relate to your intervention. I don’t see anything about a discharge phone call in this abstract. Please replace the article.

This randomized control study aim to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP). 671 individuals enrolled in the main study, 125 had a primary hospital discharge. The HF-DMP standardized SNF HF care along HF practice guidelines and performance measures and was delivered by a registered nurse called the HF nurse advocate. To accomplish this multipronged intervention, the HF nurse advocate visited enrolled patients randomized to the HF-DMP group three times over seven days and scheduled HF nurse advocate follow up in person or by phone 7-days post SNF discharge. Patients with a primary hospital discharge diagnosis of HF were included in the analysis. Baseline characteristics were compared between those who received HF-DMP versus usual care. Chi-square tests were used for categorical variables, t-tests for normally distributed continuous variables and the Wilcoxon signed-rank test for non-normally disturbed continuous variables. Descriptive statistics described adherence to quantifiable intervention components in the HF-DMP group. Composite event outcomes at 60 days and 30 days post SNF admission were compared with chi-square tests. Linear mixed models were also used to compare outcome rates to account for patient clustering at the physician level using a random effect and correlation within participant via an unstructured covariance matrix. Comment by Ginger King: Please provide statistical data. At least the p value.

Pereira Sousa, J., Neves, H., & Pais-Vieira, M. (2021). Does Symptom Recognition Improve Self-Care in Patients with Heart Failure? A Pilot Study Randomised Controlled Trial. Nursing reports (Pavia, Italy), 11(2), 418–429. https://doi.org/10.3390/nursrep11020040

In this Randomised controlled trial Pilot study does Symptom Recognition improve self-care in patients with Heart Failure. sixty-three patients in New York Self-care behaviors were measured using the 12-item European Heart Failure Self-care Behavior Scale (EHFScBS). The IG patients demonstrated a positive, progressive evolution of knowledge and understanding of HF, displaying an improvement of disease understanding in all follow-up moments ( p < 0.05; Φ > 0.5). In other words, when questioned were posed about which signs and symptoms were relevant or when asked to describe which actions to take in a given circumstance related to HF.

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

The Agency for Healthcare Research and Quality (2020), validates the use of the Re-Engineered Discharge (RED)Toolkit to conduct a post discharge follow-up telephone call to impact 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 discharge. 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 with implementing the Re-Engineered Discharge (RED) toolkit is to better prepare patients and their families for leaving the SNF and lower the number of times people must 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 : Comment by Ginger King: You were missing your PICOT. I cut and pasted it from your approved PICOT

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?

Evidence-Based Question Comment by Ginger King: Be sure to work on formatting issues throughout this document.

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, the UCSF clinical & Translational Science Institute’s sample size calculator was 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. 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 has approximately 6-10 admissions weekly. All adult patients will be qualified as a candidate for this project. Comment by Ginger King: Above you state 50 patients are seen weekly but here you state 6-10 admissions. So what do you mean by patients are seen weekly? Make sure you are clear Comment by Ginger King: All adults or all adults with heart failure diagnosis?

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 willing to participate

v) Exclusion Criteria

Who cannot Participate

· All adults without Heart Failure

· Patients not awake, alert, oriented x4

· Patients who do not speak English

· Patients not admitted for Short Term Stay

· Patients who are not willing to participate Comment by Ginger King: I fixed this for you. Your inclusion and exclusion criteria should be the exact opposite of each other.

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. Comment by Ginger King: This would be your measurable 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 the impact of readmission rates in patients with Heart Failure. This project will use a quantitative 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 a rural New Jersey skilled nursing facility. Comment by Ginger King: I fixed this for you. Be sure to use the templated statements moving forward.

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 patient specific instructions 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. Comment by Ginger King: While this is a good start, what instrument will you use (survey, electronic health records, instrument) to obtain this data and how is it determined to be valid and reliable?

iii) The tools have been tested many times among various agencies and even translated into diverse languages. Comment by Ginger King: Please include the psychometric data for reliability and validity of this tool you mentioned.

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. Comment by Ginger King: Remove templated language from the 10 SP please.

(1) The method of quality improvement will mimic quality improvement frameworks Six Sigma, Lean, as the Model for Improvement. Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in processes. A key focus of Six Sigma is the use of statistical tools and analysis to identify and correct the root causes of variation. As roadmap for problem solving and process improvement, Six Sigma uses Define, Measure, Analyze, Improve, Control (DMAIC) methodology (AHRQ, 2020). Comment by Ginger King: This doesn’t belong here. Here you should be discussing how you are going to step-by-step complete your project implementation and collect the data on your measurable outcome.

(2) For this project, the 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 respect of the decisions made by participants will be maintained to ensure participants are not harmed in way or form. All participants will be treated fairly.

Data Analysis Approach

10) Data Analysis Approach:

· A priori analysis will be used to justify the sample. Participants demographic data will be analyzed using descriptive statistics. A paired t- test will be utilized to measure readmission rates. A statistician may be used. Comment by Ginger King: Discuss potential bias and mitigation of the data.