Literature and 10 Strategic Points, Grand Canyon Un\iversity

APA Reference

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Research Questions/ Hypothesis, and Purpose/Aim of Study

Type of Primary Research Design

Research Methodology

· Setting/Sample (Type, country, number of participants in study)

· Methods (instruments used; state if instruments can be used in the DPI project)

· How was the data collected?

Interpretation of Data

(State p-value: acceptable range is p= 0.000 – p= 0.05)

Outcomes/ Key Findings

(Succinctly states all study results applicable to the DPI Project.)

Limitations of Study and Biases

Recommendations for Future Research

Explanation of How the Article Supports Your Proposed Intervention

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

Readmissions within 30 days are a challenge for the quality of healthcare, since they lead to higher costs and subpar health results. This scientific experiment will look at how well a phone call after discharge can cut down on 30-day inpatient readmissions (Yiadom et al., 2018).

Randomized Controlled Study

· 3045 participants

· The 30-day mortality rate, time to readmission, all-cause emergency department revisits within 30 days, patient satisfaction (measured as the mean Hospital Consumer Assessment of Healthcare Providers and Systems scores).

· The Vanderbilt Institute for Clinical and Translational Research Institute (VICTR) data management team collects patient visit data from the hospital's clinical data archive, the Research Derivative (Yiadom et al., 2018).

All 3054 patients discharged home were enrolled and randomized to the telephone call program (n=1534) or usual care discharge (n=1520). Using a prespecified intention-to-treat analysis, we found no evidence supporting differences in 30-day inpatient readmissions [14.9% vs. 15.3%; difference -0.4 (95% confidence interval, 95% CI), -2.9 to 2.1; P=0.76], observation readmissions [3.8% vs. 3.6%; difference 0.2 (95% CI, -1.1 to 1.6); P=0.74], emergency department revisits [6.1% vs. 5.4%; difference 0.7 (95% CI, -1.0 to 2.3); P=0.43], or mortality [4.4% vs. 4.9%; difference -0.5 (95% CI, -2.0 to 1.0); P=0.51] between telephone call and usual care groups (Yiadom et al., 2018).

Inpatient readmission within 30 days after hospital release, censored for death, is our main goal. We took into account the 30-day inpatient readmission or death composite outcome. On the other hand, we discovered that the 30-day death rates in our general medicine population were 2.6% the year before. This shows that the risk of mortality is not a large competing concern and that there would be little trouble with informative censoring22. All-cause emergency department (ED) revisits within 30 days, observation status readmission within 30 days, time to readmission, patient satisfaction (measured as mean Hospital Consumer Evaluation of Healthcare Providers and Systems ratings), and 30-day mortality are examples of secondary endpoints. Exploratory outcomes include the number of call attempts necessary for successful intervention delivery and the requirement for assistance with discharge plan execution among participants who were randomly assigned to the intervention arm and contacted by the research nurse.

To increase generalizability, a single-center trial was carried out in a tertiary care referral facility with only the general medicine population included.

designed to show effectiveness while making practical compromises (such as an expected 30% intervention delivery rate) that restrict our ability to assess efficacy.

The right choice of more pragmatist and less explanatory design components was made in response to the requirement to support a time-sensitive clinical practice decision in the context of clinical equipoise.

Study feasibility was made possible by the waiver of permission and the utilization of clinical informatics tools (Yiadom et al., 2018).

The structure, goal, and purpose of a subsequent iteration of the discharge follow-up phone call program will be informed by study findings, which will also be submitted for publication in future literature (Yiadom et al., 2018).

The Phone Call RN verifies the disposition of the discharge and then examines the medical file to ascertain what was anticipated to happen following hospital discharge, such as medication adjustments, follow-up appointments, education for new diagnoses, and symptoms for which urgent care should be sought. This article will support the DPI project intervention.

Biese, K. J., Busby-Whitehead, J., Cai, J., Stearns, S. C., Roberts, E., Mihas, P., Emmett, D., Zhou, Q., Farmer, F., & Kizer, J. S. (2018). Telephone Follow-Up for Older Adults Discharged to Home from the Emergency Department: A Pragmatic Randomized Controlled Trial. Journal of the American Geriatrics Society, 66(3), 452–458. https://doi.org/10.1111/jgs.15142

To identify barriers to accessing medication, receiving post-discharge instructions, and obtaining physician follow-up, an intervention that comprised a telephone call from a nurse utilizing a scripted questionnaire was included. Only a satisfaction survey was administered to the control group (Biese et al., 2018

Pragmatic Randomized Controlled Trial

· A total of 120 patients completed the study. located in Southeastern United States.

· A trained nurse called intervention group patients 1 to 3 days after each patient's index ED visit to review discharge instructions and help with discharge plan compliance. Patients in the placebo call group received a patient satisfaction survey call, while patients in the control group were not called.

· For all three groups, data collection calls took place five to eight days and thirty to thirty-five days after the index ED visits. For categorical data, chi-square or Fisher's exact tests were run, and the Kruskal-Wallis test looked at group differences in follow-up times (Biese et al., 2018

p= 0.04

120 patients in all finished the research. Patients had a mean age of 75 years (SD = 7.58 years), were 60% female, and were 72% white. Patients in the intervention group were more likely than those in the control or placebo groups to follow up with doctors within five days of their ED visits (54, 20, and 37%, respectively; p = 0.04). The acquisition of medications and the understanding of dosage and indications were strong points for all groups. When compared to patients in the placebo or control groups (22, 33, and 27%, respectively; p = 0.41), there were no differences in the number of return visits to the emergency department or hospital within 35 days of the index ED visit for intervention patients. According to an economic analysis, there is a 70% possibility that this action will lower overall expenses (Biese, et al., 2018)

The study was carried out at a single facility that is a part of a major healthcare network that has a wide range of providers. In comparison to more isolated EDs, this system may be better equipped to schedule prompt follow-up appointments.

Second, certain possible sources of bias were offered by the requirement to randomize and consent patients after they left the ED. Patients in the control group got their first calls from the research assistant 5 to 8 days after their initial ED visits, whereas participants in the intervention and placebo groups got their calls 1 to 3 days after discharge (Biese et al., 2018).

Further research is required to ascertain whether this intervention can lessen repeat visits to the ED and/or hospitalizations, show cost savings, and apply these findings to new sites and patient populations (Biese et al., 2018

An older adult receiving a pre-recorded phone call from a qualified nurse after being released from the ED did not result in a decrease in 30-day mortality rates or ED or hospital re-admission rates. The goal of this intervention is to reduce 30-day readmission using a telephone call; therefore, this article can support the project intervention (Biese et al., 2018

Hwang, B., Huh, I., Jeong, Y., Cho, H.-J., & Lee, H.-Y. (2022). Effects of educational intervention on mortality and patient-reported outcomes in individuals with heart failure: A randomized controlled trial. Patient Education & Counseling, 105(8), 2740–2746. https://doi-org.lopes.idm.oclc.org/10.1016/j.pec.2022.03.022

To investigate the impact of an educational intervention on heart failure (HF) patients' patient-reported outcomes with telephone follow-up (Hwang et al., 2022)

Randomized Controlled Study

· 122 hospitalized patients with HF. The intervention group (n = 60) received an individual nurse-led education session on HF self-management during hospitalization and three telephone calls after discharge, with HF were recruited from inpatient units at a university-affiliated hospital located in Seoul, South Korea.

· To determine the degree of health literacy, we employed the Short Form Korean Health Literacy Scale. This questionnaire consists of 12 items that assess older persons' reading and comprehension skills when it comes to medical information. The total scores may be between 0 and 12.

· Research staff conducted structured interviews to collect sociodemographic and clinical data from patients, using questionnaires and medical records (Hwang et al., 2022).

p=.004

7 fatalities (12%) occurred in the intervention group throughout the follow-up (median: 568 days); 15 deaths (24%) happened in the control group (adjusted hazard ratio, 0.40; 95% confidence range, 0.16-0.98; p =.046). From baseline to 3 and 6 months, the intervention group showed greater improvements in HF knowledge (difference=6.14, p = .03; difference=5.76, p = .02, respectively), self-care (difference=-6.08, p < .001; difference=-6.16, p< .001, respectively), and health-related quality of life (difference=-11.90, p = .01; difference=-14.57, p = .004, respectively) than the control group (Hwang et al., 2022).

This research has several restrictions. The findings can only be applied to environments that are similar because the study was conducted at a single center. In addition, despite our efforts to meet the enrollment target, we were unable to reach the desired sample size (Hwang et al., 2022).

Although it did not obfuscate the intervention's impact on patient outcomes, our findings should be regarded cautiously and require future research validation (Hwang et al., 2022).

According to Hwang et al. (2022), telephone follow-up and educational intervention decreased all-cause mortality and enhanced patient-reported outcomes. Therefore, this study will help support the DPI project.

van Loon-van Gaalen, M., van der Linden, M. C., Gussekloo, J., & van der Mast, R. C. (2021). Telephone follow-up to reduce unplanned hospital returns for older emergency department patients: A randomized trial. Journal of the American Geriatrics Society, 69(11), 3157–3166. https://doi.org/10.1111/jgs.17336

Since unplanned hospital admissions and/or ED return visits within 30 days were a concern, the aim of this study was to investigate the impact of a telephone follow-up call for community-dwelling patients aged 70 and older after discharge from the ED (van Loon-van et al., 2021).

Randomized Controlled Trial

· The trial was conducted in two emergency departments at HMC, an inner-city, non-academic teaching hospital in The Hague, The Netherlands. In 2018, the Westeinde site saw 53,000 patients, 18% of whom were 70 years of age or older, while the Bronovo location had 28,000 patients, 25% of whom were under the age of 70.

· Telephone follow-up questionnaire for patients over the age of 70.

· An information technology specialist who was not involved in the study abstracted demographic information, ED visit data, ED return visit data, and hospitalization data from the EHS. The data was then organized by a researcher who was blind to the study groups. We followed Worster's recommended approaches for data abstraction (van Loon-van et al., 2021).

p = 0.42

During the study period, 9836 community-dwelling patients aged 70 years and older were discharged home from the ED, 4732 in odd months, and 5104 in even months. Due to shortage of staff, trained ED nurses were not able to call 40% of eligible patients in the intervention group and 36% of patients in the control group ( p < 0.001). In the intervention group, 32% could not be reached, compared with 31% in the control group ( p = 0.42) (van Loon-van et al., 2021).

Patients with cognitive impairment or mental illnesses were not allowed to participate in Biese's trial, despite the fact that they have a high chance of returning to the hospital. Moreover, the impact of phone follow-up on unforeseen hospital hospitalizations and repeat ED visits was not studied. 4 Even though these restrictions were removed for our most recent trial, the outcomes were consistent. The Biese experiment had a flaw that we were unable to fix—patients' limited telephone accessibility. Our patient recruitment success rates were comparable to those of other research (van Loon-van et al., 2021).

Data indicate that telephone follow-up increases patient satisfaction, feelings of loneliness, and depressive symptoms in older patients at risk who were discharged from the ED, even if a positive effect on hospital returns was not discovered. This might be looked at in a later study (van Loon-van et al., 2021).

Telephone follow-up and sharing discharge information are two examples of socially complicated interventions that may be impacted by patient and environmental factors as well as healthcare provider-level confounders. A possible benefit of telephone follow-up could be increased by educating doctors and nurses in geriatric competencies, such as communication and shared decision-making (van Loon-van et al., 2021). This information can be supporting to the DPI project.

Patel, P. H., & Dickerson, K. W. (2018). Impact of the Implementation of Project Re-Engineered Discharge for Heart Failure patients at a Veterans Affairs Hospital at the Central Arkansas Veterans Healthcare System. Hospital pharmacy, 53(4), 266–271. https://doi.org/10.1177/0018578717749925

This study aims to evaluate Project Re-Engineered Discharge (RED) implementation's effects on the frequency of hospital readmissions, all-cause mortality, primary care physician follow-up rate, and cost savings for HF patients (Patel & Dickerson, 2018).

Single-center, retrospective, cohort study

· Patients admitted with HF exacerbation at the Central Arkansas Veterans Healthcare System (CAVHS), The study included a random sample of 50 patients treated after Project RED intervention and 100 patients admitted before Project RED was implemented.

· Pearson's chi-square test was used to compare baseline variables, primary outcome, and secondary outcomes, with P values under 5. Principal author responsible for data analysis.

· All data outcomes collection and analysis were performed by primary author (Patel & Dickerson, 2018).

p = .04

To enhance patient outcomes and safety while lowering total health care costs, institutions should implement care coordination utilizing a discharge tool like Project RED (Patel & Dickerson, 2018).

It is important to be aware of the limitations of this study. The fact that this review was retroactive lends itself to various biases. Male patients made up the bulk of the study's patients, which lessens the study's external validity (Patel & Dickerson, 2018).

According to the findings of this study, it would be advised for future interventions to schedule PCP appointments at the time of discharge (Patel & Dickerson, 2018).

This study was to enhance patient outcomes and safety while lowering total health care costs, institutions using implement care coordination utilizing a discharge tool like Project RED. This study support the DPI project by using Project RED to enhance follow up discharge instructions.

APA Reference

(Include the GCU permalink or working link used to access the article.)

Research Questions/ Hypothesis, and Purpose/Aim of Study

Type of Primary or Secondary Research Design

Research Methodology

· Setting/Sample (Type, country, number of participants in study)

· Methods (instruments used; state if instruments can be used in the DPI project)

· How was the data collected?

Interpretation of Data

(State p-value: acceptable range is p= 0.000 – p= 0.05)

Outcomes/ Key Findings

(Succinctly states all study results applicable to the DPI Project.)

Limitations of Study and Biases

Recommendations for Future Research

Explanation of How the Article Supports Your Proposed DPI Project

Mwachiro, D. M., Baron-Lee, J., & Kates, F. R. (2019). Impact of post-discharge follow- up calls on 30-day hospital readmissions in neurosurgery. Global Journal on Quality and Safety in Healthcare, 2(2), 46–52. https://doi.org/10.4103/jqsh.jqsh_29_18

Impact of Post-Discharge Follow-Up Calls on 30-Day Hospital Readmissions (Mwachiro et al., 2019).

A Plan–Do–Study–Act methodology

· In total, 83 patients were included in the analysis. Of these, 45% (n = 37) received a follow-up call after they were discharged from initial admission.

· Follow up Phone call

· Medical insurance claims data, also known as claims-based data in the American health care system, were reviewed and analyzed to assess whether there was any difference in number of days from initial discharge to readmission between patients who received a follow-up call and those who did not (Mwachiro et al., 2019).

p = 0.005

Readmitted patients who received post-discharge follow-up calls had significant improvements in the length of time out of the hospital. Future development could include developing additional call strategies (Mwachiro et al., 2019).

The problem with utilizing clinical staff to initiate follow-up calls post-discharge is that it adds to their list of responsibilities and many dislike making post-discharge calls with over 20% affirming that they would rather do any other task (Mwachiro et al., 2019).

Future development could include developing additional call strategies and identifying patients at higher risk of readmission. Further studies need to be completed because the results from this single-center cannot necessarily be generalized to other institutions (Mwachiro et al., 2019).

The study findings suggest that readmitted patients who received follow-up calls post-discharge had significant improvements in the length of time out of hospital compared to those that did not receive a follow-up call post-discharge (Mwachiro et al., 2019).

Vernon, D., Brown, J. E., Griffiths, E., Nevill, A. M., & Pinkney, M. (2019). Reducing readmission rates through a discharge follow-up service. Future healthcare journal, 6(2), 114–117. https://doi.org/10.7861/futurehosp.6-2-114

Cohort study

· 756 patients were located throughout seven hospital wards; 303 were chosen for the intervention and 453 were placed in a comparison group. The intervention was chosen for patients who were over 65 and registered at a general practitioner (GP) that was a part of the Solihull Clinical Commissioning Group (CCG).

· Data on hospital admissions and readmissions for patients who received the intervention and the comparison group were taken between January 1, 2016, and June 30, 2016, one month after the trial's six-month end, from the HEFT computer system (icare) (Vernon et al., 2019).

·

p=0.033

Patients who may have gotten the intervention but were not contacted are included in the exposure group, which raises the possibility of misclassification bias. This provides an effect size that may be a more accurate representation of the intervention's potential impact in the real world, where some patients may not be able to use the service. The risk of loss to follow-up in the cohort is decreased by the short duration of the study and the removal of patients who passed away (Vernon et al., 2019).

The results also imply that additional research will need to examine the wider consequences and expenses of providing this service. In addition to increasing community and primary care service activity, these effects include the sustainability of interventions outside of the secondary care context. Future research will need to take into account additional patient health and wellbeing outcome metrics (Vernon et al., 2019).

Du, R. Y., Shelton, G., Ledet, C. R., Mills, W. L., Neal-Herman, L., Horstman, M., Trautner, B., Awad, S., Berger, D., & Naik, A. D. (2020). Implementation and feasibility of the re-engineered discharge for surgery (RED-S) intervention: A pilot study. Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality, 00, 1-9. https://doi.org/10.1097/JHQ.0000000000000266

Implementation and feasibility of the re-engineered discharge for surgery (RED-S) intervention (Du et al., 2020).

Pilot Study

· Participants 100, implementation of RED-S occurred on surgical services at our hospital, a large tertiary care medical center consisting of three acute surgical care units, one step down surgical unit, and one surgical intensive care unit for general surgery.

· RED-S bundle component.

· For RED-S participants, we surveyed via telephone all participants approximately 30 days following discharge to administer each of these four composite measures (Du et al., 2020).

P=0 .5

Patients received postoperative education on wound care because this component integrated easily with existing processes. Among the nine ostomy patients, seven (77%) received a documented enter ostomy therapy nursing consultation with education on management of ostomies (du et al., 2020).

This is a pilot study intended to establish proof of concept. It was conducted at a single tertiary referral center and enrolled primarily older men, which may limit the generalizability. Adherence rates for some intervention components were lower than desired, but this finding may represent underreporting and poor documentation by chart review because omissions of details in EMR are common (Du et al., 2020).

Opportunities for further investigation in the implementation and impact of the RED-S intervention include its potential relationship with reducing postsurgical hospital readmissions (Du et al., 2020).

The RED-S intervention standardizes the hospital discharge process with the goal of improving care transitions and readmission rates for colorectal surgery patients. This pilot study shows promise for the feasibility of implementation of RED-S and provides proof of concept of the positive impact of the RED-S intervention on patient-reported experiences (Du et al., 2020).

Mitchell, S. E., Reichert, M., Howard, J. M., Krizman, K., Bragg, A., Huffaker, M., Parker, K., Cawley, M., Roberts, H. W., Sung, Y., Brown, J., Culpepper, L., Cabral, H. J., & Jack, B. W. (2022). Reducing Readmission of Hospitalized Patients With Depressive Symptoms: A Randomized Trial. Annals of family medicine, 20(3), 246–254. https://doi.org/10.1370/afm.2801

To determine if hospitalized patients with depressive symptoms will benefit from post-discharge depression treatment with care transition support (Mitchell et al., 2022).

Randomized Control Study

· 709 participants in Boston Massachusetts

· Baseline sociodemographic data, Rapid Estimate of Adult Literacy in Medicine, 20 Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), 2

· During recruitment, study staff reviewed a daily list of hospitalized patients admitted within 24 hours and assessed eligibility using medical records (Mitchell et al., 2022).

p = .003

Care transition support and post discharge depression treatment can reduce unplanned hospital use with sufficient uptake of RED-D intervention (Mitchell et al., 2022).

This study also has several limitations. Because we observed an effect of the RED-D intervention in the as-treated analysis but not the intention-to-treat analysis, we strongly suspect that low study adherence was responsible for the null (Mitchell et al., 2022).

Assignment to the RED-D intervention by itself does not produce a detectable effect. Therefore, future studies is recommended (Mitchell et al., 2022).

This research showed that a systematic approach to hospital discharge can reduce 30-day readmissions and emergency department visits (Mitchell et al., 2022).

Cui, X., Zhou, X., Ma, L. L., Sun, T. W., Bishop, L., Gardiner, F. W., & Wang, L. (2019). A nurse-led structured education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure: a randomized and controlled trial in China. Rural and remote health, 19(2), 5270. https://doi.org/10.22605/RRH5270

Nurse-led structured education program improves self-management skills and reduces hospital readmissions in patients with chronic heart failure (Cu et al., 2019).

Randomized Controlled Trial

· Ninety-six patients in the eastern Chinese province of Shandong with CHF were randomly divided into intervention and control groups

· Statistical analysis was completed using the Statistical Package for the Social Sciences v16.0 (IBM; http://www.spss.com).

· A Fisher’s exact t-test was used to analyze categorical data, and an independent t-test was used for numerical data. A p-value ≤0.05 was considered statistically significant (Cu et al., 2019).

p=0.036

The primary endpoint of the study was all-cause mortality and hospital admission due to cardiac problems, such as shortness of breath, chest pain, arrhythmia, and syncope. Information on hospital readmission was obtained from the patients and confirmed by reviewing the medical charts at the cardiology or emergency department (Cu et al., 2019).

This study was limited by the small study population in only one region in rural China. Although the patients were representative of the demographics of heart failure patients in this region, the applicability of findings to other patient populations is yet to be evaluated (Cu et al., 2019).

In addition, cognitive function and other comorbidities, which were not analyzed in this study, may also impact on the outcomes of CHF. Therefore, future studies are recommended (Cu et al., 2019).

This study has demonstrated that a structured education program was associated with a significant improvement in medication adherence, dietary modifications, social support, and symptom control in rural CHF patients. Furthermore, this program was associated with a significant reduction in hospital readmission and would be beneficial to the DPI (Cu et al., 2019).

Popejoy, L. L., Vogelsmeier, A. A., Wang, Y., Wakefield, B. J., Galambos, C. M., & Mehr, D. R. (2021). Testing Re-Engineered Discharge Program Implementation Strategies in SNFs. Clinical nursing research, 30(5), 644–653. https://doi.org/10.1177/1054773820982612

Quantitative results of a multimethod study testing two different RED program implementation strategies in SNFs (Popejoy et al., 2021).

Multimethod study

· 450 participants in Boston, MA

· Data sources included Master Beneficiary Enrollment for Medicare A/B (MBSF), Beneficiary Chronic Conditions, Inpatient Services, Non-institutional Provider, SNF Provider, Home Health Agency (HHA) Provider, and Minimum Data Set (3.0) (MDS) files.

· Pretest-posttest design (Popejoy et al., 2021).

p = .01

They also had statistically significantly less functional impairment as measured by ADL self-performance (11.6, SD 5.3) compared to 2015 (12.5, SD 5.3, p < .05) and had a higher Charlson Comorbidity Index score (4.65, SD 3.3 vs. 3.97, SD 3, p < .001). There were fewer occupational and physical therapy minutes in 2013, but this difference was not statistically significant. (Popejoy et al., 2021).

This study took place in four SNFs located in a Midwestern midsize city in rural part of the state, thus findings cannot be generalized to large urban areas. During the course of the study, facilities experienced leadership changes, staffing shortages, and building repair issues which may have impacted the results of the study (Popejoy et al., 2021).

Other outcome measures introduced in this study such as SNF readmission may be useful to consider in future studies (Popejoy et al., 2021).

Implementation of a SNF RED program to prepare patients for discharge to the community showed promise in some of the facilities in our study. Combined with findings of others, the RED program holds promise as an approach to avoiding hospital readmissions following SNF discharge. In our study, a slower implementation strategy worked best to allow SNFs to consider how to most effectively implement new discharge processes. However, context rather than the specific intervention may have been the critical component (Popejoy et al., 2021).

Popejoy, L. L., Wakefield, B. J., Vogelsmeier, A. A., Galambos, C. M., Lewis, A. M., Huneke, D., Petroski, G., & Mehr, D. R. (2020). Reengineering Skilled Nursing Facility Discharge: Analysis of Reengineered Discharge Implementation. Journal of nursing care quality, 35(2), 158–164. https://doi.org/10.1097

To describe implementation of Re-engineered Discharge (RED) Process in SNFs and makes recommendations for its future implementation (Popejoy et al., 2021).

Mixed methods study

· 120–132 bed participants

· Detailed field notes were recorded for every encounter between SNF staff and study staff. At baseline, SNFs described their existing discharge processes including stakeholders affected by the discharge process (e.g., provider, families, and community agencies). These data were then mapped and presented to the SNF staff to verify that the discharge process as described was accurate.

· Detailed field notes were recorded for every encounter between SNF staff and study staff (Popejoy et al., 2021).

p = .001

There were 58 staff who completed the Staff Satisfaction with RED survey; the majority were nurses (RN/LPN, n = 31, 53%), followed by leadership, physicians, therapists (n= 12, 21%), licensed social workers/social work designees (n= 11, 19%), and 4 (7%) did not give a role designation. Staff satisfaction with discharge process results can be found in Supplemental Digital Content (Popejoy et al., 2021).

There were study limitations. This was a small-scale implementation study that took place in a specific region. This was a nonprobability sample. There was turnover in SNF leadership and staff over the course of the study, particularly in 1 Enhanced SNF (Popejoy et al., 2021).

Future approaches might include identification of an internal facilitator or change agent, i.e., someone employed within the SNF, who could work with an external facilitator. Staff may feel uncomfortable with new roles, e.g., patient education or coordination of care with primary care offices, thus some staff education may be required to facilitate change (Popejoy et al., 2021).

This study proved that SNFs can use RED to enhance the discharge procedures. SNFs require a means to prioritize their efforts to enhance the discharge process because it is difficult to incorporate all RED components at once. Implementation frameworks like CFIR may be helpful to utilize when companies are considering significant changes to their discharge programs as a method to comprehend present discharge procedures, external factors, SNF resources, and the organization's capacity for change (Popejoy et al., 2021).

Roberts, S., Moore, L. C., & Jack, B. (2019). Improving discharge planning using the re- engineered discharge programme. Journal of Nursing Management, 27(3), 609- 615. https://doi.org/10.1111/jonm.12719

a) Assess nurses’ readiness to learn (RTL) before receiving education on the re-engineered discharge (RED) programme and (b) measure utilization of the RED discharge process from patient chart reviews following an educational intervention (Roberts, Moore, & Jack, 2019).

Systemic Review

· Sixty-nine participants (69) Rural U.S.A

· Chart reviews found usage of the RED 12 actionable item pre-intervention.

· Measure utilization of the RED discharge process from patient chart reviews following an educational intervention (Roberts, Moore, & Jack, 2019).

p = 0.000

Participants scored high M = 219.8 ( SD 23.7) on the SDLR, indicating nurses’ high RTL prior to educational intervention. Chart reviews found usage of the RED 12 actionable item pre-intervention, ( n = 60) M = 6.55 ( SD 1.478) compared to post-intervention ( n = 60) M = 10.08 ( SD 1.544) indicated statistically significant improvement in pre-discharge patient education and planning ( t = 17.730, p = 0.000 [CI 3.13–3.93]) (Roberts, Moore, & Jack, 2019).

Rural areas are at a disadvantage, due to decreased access to health care and other disparities (Roberts, Moore, & Jack, 2019).

Future Studies is recommended in assessing nursing readiness to learn RTL.

Current study found that nurses with higher levels of RTL who underwent RED educational sessions significantly improved delivery of the RED process documented in the medical record (Roberts, Moore, & Jack, 2019).

Weerahandi, H., Li, L., Bao, H., Herrin, J., Dharmarajan, K., Ross, J. S., Kim, K. L., Jones, S., & Horwitz, L. I. (2019). Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study. Journal of the American Medical Directors Association, 20(4), 432–437. https://doi.org/10.1016/j.jamda.2019.01.135

Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization (Weerahandi et al., 2019).

Retrospective cohort study

· All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home.

· Study population characteristics were summarized with descriptive analyses.

· They utilized piecewise exponential Bayesian models to partition the time scale in order to estimate baseline hazard of readmission (Weerahandi et al., 2019).

P=0.05

In order to examine readmission patterns among homogenous sets of patients to inform our final model, 30 cohorts were created for patients with SNF stays of 1 to 30 days, respectively. We then plotted the percentage of readmissions that occurred on each day (0-30) after discharge from SNF for each of these cohorts (Weerahandi et al., 2019).

This analysis differs from prior work in that it focuses on readmission and mortality after SNF discharge, not during SNF stay.1, 36, 37 The few studies that have examined outcomes from SNF to home did not use national data (Weerahandi et al., 2019).

Further work should examine if formal discharge practices currently used in hospitals could be applied to the transition from SNF to home (Weerahandi et al., 2019).

Discharge from hospital to skilled nursing facility (SNF) is common in heart failure patients. The 30-day readmission risk during the transition from SNF to home is almost 25%. Readmission risk decreases as SNF length of stay increases (Weerahandi et al., 2019).

Zingmond, D. S., Liang, L. J., Parikh, P., & Escarce, J. J. (2018). The Impact of the Hospital Readmissions Reduction Program across Insurance Types in California. Health services research, 53(6), 4403–4415. https://doi.org/10.1111/1475-6773.12869

Examine 30-day readmission rates for indicator conditions before and after adoption of the Hospital Readmissions Reduction Program (HRRP).

Cohort Study

· Sample consisted of 333,640 heart attack in California hospital

· The pre-HRRP period included data from 2005 through the third quarter of calendar year 2012 (31 quarters), while the post-HRRP period included the fourth quarter of calendar year 2012 through 2014 (nine quarters).

· Using the CMS definitions, were measured 30-day unplanned readmission for each of these cohorts (Yale New Haven Health Services Corporation 2016)

p=0.01

Post-HRRP, reductions occurred for the three conditions among Fee-for-Service (FFS) Medicare. Readmissions decreased for heart attack and heart failure in Medicare Managed Care (MC). No reductions were observed in the younger commercially insured (Zingmond et al., 2018).

This is a retrospective study of hospital readmissions using data from a single, albeit large, state. Findings may not generalize outside of California. These retrospective data cannot assign causality to the observed trend changes.

Future work should focus on the underlying mechanisms mediating these changes.

In the period after the introduction of the HRRP, greater than expected reductions have occurred in unplanned rehospitalizations both for patients with Medicare FFS and for those in Medicare MC.

Nursing Theory Selected

APA Reference – Seminal Research References

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Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project

Orem’s Theory on Self-Care Deficit

Orem, D. E . (1971). Nursing: Concepts of practice. New York: McGraw-Hill.

Orem’s theory offers a sufficient theoretical basis for nursing practice in basic healthcare settings. Primary care nurses can offer care for a person as an important part of a wider family and society by putting this theory principles into reality. This theory can help in the DPI project by DNP learner viewing their patient as someone who can establish and adopt a self-care routine. One useful outcome of using the theory is that Nurses can analyze their clinical practice using nurse-sensitive metrics. Orem's theory offers a helpful framework for considering patient care, which helps us better understand the ongoing fluidity and adaptation of advanced nursing practice and fundamental healthcare.

Change Theory Selected

APA Reference - Seminal Research References

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Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention

Rogers’ Diffusion of Innovations Theory

Rogers, E. M. (1962). Diffusion of innovations. New York, Free Press of Glencoe.

According to the Diffusion of Innovation (DOI) theory developed by Rogers in 1962, "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 (Rogers, 1962) demonstrates how ideas become ingrained within a context by utilizing the social system, time, communication channels, and the suggested new idea as a key component of the theory to accomplish change.

APA Reference - Clinical Guideline

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APA Reference - Original Research (All)

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Explanation for How Clinical Practice Guidelines Align to DPI Project

Agency for Healthcare Research (2020). Re-Engineered Discharge (RED) Toolkit. Content last reviewed February 2020. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html

Agency for Healthcare Research and Quality (2013). Re-engineered Discharge (RED) Toolkit. Content last reviewed March 2013. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool1.html

The goal of this DPI project is to reduce 30-day readmissions using a follow up phone after patients are discharged from the SNF. According to the guidelines this tool outlines the numerous procedures discharge educators carry out to execute the RED components, ranging from coordinating medication lists to going over the patient's After Hospital Care Plan (AHCP). The tool comes with instructions on how to make an AHCP, a patient-friendly pamphlet that explains how to take care of themselves after leaving the hospital. Therefore, this guidelines can also be used in the SNF setting.