Literature and 10 Strategic Points, Grand Canyon Un\iversity

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 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

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. I don’t see anything about a discharge phone call in this abstract. Please replace the article.

Effects of the patient education strategy “Learning and Coping” in cardiac rehabilitation on readmissions and mortality: Comment by Ginger King: This is word for word from the abstract/title. It doesn’t tell you reader anything about the research article.

Randomized Controlled Study

· In all, 825 patients with ischaemic heart disease or heart failure were randomized to the intervention arm (LC-CR) or the control arm (standard CR) at three hospitals in Denmark.

· The patient characteristics in the two arms at baseline were compared descriptively using chi-squared tests for the binary and categorical variables and an unpaired Student's t test for the continuous variables

· The randomization procedure was applied independently of the research team using a web-based system and stratified for gender, diagnosis (IHD or HF) and hospital unit [[23]].

p = 0.06. Comment by Ginger King: Your stats need to be directly related to the intervention of a discharge phone call. This p value has nothing to do with a phone call. In fact, I cannot tell with how the abstract is written what this p value relates to.

In all, 1642 patients with IHD or HF were approached and 827 were successfully recruited (Fig. 1) [[34]]. Two patients were excluded due to being randomized in error. Of the remaining 825 patients, 413 were allocated to the LC arm and 412 to the control arm. The clinical and demographic characteristics of the non-participants were not collected. The number of allocated assigned health professionals in the LC arm was 13, and the number of experienced patients was 10 throughout the trial period (Fig. 1). In the control arm, the number of health professionals was 16

Given the independently implemented randomization, the block and stratified randomization and the significance level of 5%, this explorative study based on the LC-REHAB trial is likely to be subject to a low risk of Type I error, selection bias and confounding. Furthermore, the exposures—LC trial arm or control trial arm—did not lead to misclassification bias. However, it was not possible to blind the patients or health professionals due to the nature of the intervention, leading to risk of differential information bias regarding outcomes. Nevertheless, the explorative outcomes of this study (deaths or readmissions) are not self-reported, and thus give no rise to concern of bias.

The study was not sufficiently powered to detect between-arm differences in mortality or readmissions. Therefore, there was a risk of overseeing a real effect of adding LC to CR. Moreover, further research—preferentially in a mixed methods design in which the characteristics as well as needs of the non-participants are collected, is needed to evaluate which characteristics must be addressed and which components are important in developing effective patient education interventions to patients with IHD or HF in the future.

· In this article it shows ow patient education aims to encourage patients to take active part and responsibility in managing risk and lifestyle factors and improving coping strategies. Use of the Re-Engineered Discharge follow-up phone call will help persons in the teaching in either joint education with health professionals or sole lay-led education to promote self-managing process in patients after discharge from SNF.

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, 101–111. https://doi-org.lopes.idm.oclc.org/10.1016/j.ijnurstu.2017.07.015

An evaluation of involving family caregivers in the self-care of heart failure patients on hospital readmission Comment by Ginger King: Please edit this to explain what this article is about. You need to mention your intervention.

Randomized Controlled Study

· 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).

( p=0.02)

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).

Despite using block randomization, the two groups differed in size by four participants; this is attributed to collection of data from three sites, which may have affected the efficiency of the implementation of the block randomization. Moreover, although the researcher collecting the follow-up data was blinded to the group allocation of the participants, participants were aware of their group allocation and this could have produced reporting bias due to social desirability.

This information should be included in future trials since it points to the severity of the conditions and is a good reflection of the quality of care provided during hospitalization

· 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.

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.

Randomized Controlled Study

· The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).

· 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. This can be used for in the DPI project.

· 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.

The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.

The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.

The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant.

This research should be included in future research focusing on the skilled nursing facility and managing heart failure symptoms to reduce readmission.

· This article supports the DPI project in how to manage patients’ symptoms of patient with Heart Failure in the SNF.

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.

To determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP).

Randomized Controlled Trial

· 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. Can be used for this Project.

· 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.

Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79±10, 53% women, mean ejection fraction 46±15%. At 60 days post-SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared to usual care (52%) (p=0.02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% versus 31% in the usual care group (p=0.11).

The primary outcome of interest was a composite of rehospitalization, ED visits or mortality (whichever occurred first) by 60-days post SNF admission. This captured both the SNF inpatient stay and the SNF post discharge period for most patients. Outcomes were obtained from the SNF chart and a phone call to the participants at 7-days post-SNF discharge and 60-days post-SNF admission. Additionally, the Colorado Regional Health Information Organization was used to identify ED visits and rehospitalizations and the National Death Index was used to confirm death. The addition of these methods was critical to ensure accurate results.

While the main study was a randomized controlled trial, this was a secondary post-hoc analysis of a sub-group of patients with a primary hospital discharge diagnosis of HF. However, patients were similar between the HF-DMP and usual care groups in this subgroup analysis.

Future research is needed for patients in the skilled nursing setting.

· Patient discharge to SNF often is not a choice, but a necessity driven by deconditioning therefore, this article to help with interventions to educated the patients on to help being compliant with care on discharge.

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 Comment by Ginger King: 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 article. Please replace the article.

Does Symptom Recognition Improve Self-Care in Patients with Heart Failure?

Randomised controlled trial Pilot study

· On sixty-three patients in New York

Sample characteristics show a higher percentage of men (74.60%) living with a com- panion (69.84%), with no significant difference between the IG and CG (range: 73.33–75.76; p = 0.825; d = 0.056). The mean age was 54.83 years (10.28), with no significant difference (p = 0.630; d = 0.122) between the CG [54.42 (10.54)] and the IG [55.27 (10.15)

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 Comment by Ginger King: This is all word for word from the article. This needs to be fixed so that it does not appear to be plagiarized.

This was a pilot study, and therefore the main limitation to the interpretation of the present results is the sample size. In addition, the present study did not precisely control for the possibility of patients finding the information given in the intervention to be too complex or confusing.

In future studies, mobile apps implementation can be a helper for symptom recognition through programs that use artificial intelligence to recall signs and symptoms, help the interpretation of those, and contact healthcare professionals, if required.

This pilot study focused on creating a symptom management intervention and included it in a nurse-led program was created to enhance self-care practices and lower hospitalization rates for HF patients. Self-care is complicated, and by creating an instructional area, such as one on fluid restriction, HF sufferers may be better able to balance their control over their health state. This intervention would be beneficial to the DPI project.

APA Reference

(Include the GCU permalink or working link used to access the article.) Comment by Ginger King: I have not reviewed these articles. It is up to you to review and make sure they are acceptable for this project. Please replace those articles that are not.

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

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

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.

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.

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.

· 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.

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

Telephone Follow-Up for Older Adults Discharged to Home

Randomized Controlled Study

· The sample size was based on a pilot study of 544 patients, conducted in HMC, reporting a differenceof 3% in all hospital admissions after 30 days between the intervention and the control group.

· Patients included in odd months received an intervention telephone call and patients included in even months received a satisfaction survey telephone call.

· Demographic data, data related to the patients' ED visits, and data concerning ED return visits and hospitalizations within 30 days after ED discharge were abstracted from the EHS by an information technology specialist.

(p=0.42

In the control group, 77 of the 1659 patients (4.6%) received some form of advice or information in addition to the satisfaction survey. After excluding these patients from analysis, the results of the primary and secondary outcomes remained unchanged.

The limited telephone accessibility of patients was a limitation of Biese's trial that we could not overcome

Evaluating the effects of a telephone intervention in these subgroups in future research is important.

· This study did not find a beneficial effect of a telephone follow-up call on reducing unplanned hospital admissions and/or ED return visits. Therefore, this would not benefit the DPI project.

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

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.

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.

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.

Opportunities for further investigation in the implementation and impact of the RED-S intervention include its potential relationship with reducing postsurgical hospital readmissions.

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

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

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

10% decrease in the rate of readmissions (P = .003)

Care transition support and post discharge depression treatment can reduce unplanned hospital use with sufficient uptake of RED-D intervention

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

Assignment to the RED-D intervention by itself does not produce a detectable effect. Therefore, future studies is recommended.

This research showed that a systematic approach to hospital discharge can reduce 30-day readmissions and emergency department visits.

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

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.

( 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.

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.

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.

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.

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

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

( 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.

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.

Other outcome measures introduced in this study such as SNF readmission may be useful to consider in future studies

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, 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.

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

p = .001

here 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

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.

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.

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.

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.

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.

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]).

Rural areas are at a disadvantage, due to decreased access to health care and other disparities.

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.

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

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

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.

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.

Further work should examine if formal discharge practices currently used in hospitals could be applied to the transition from SNF to home.

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

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, we 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 fail- ure in Medicare Managed Care (MC). No reductions were observed in the younger commercially insured.

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

Yip, J. Y. C. (2021). Theory-Based Advanced Nursing Practice: A Practice Update on the Application of Orem’s Self-Care Deficit Nursing Theory. SAGE Open Nursing. https://doi.org/10.1177/23779608211011993 Comment by Ginger King: Replace this with the seminal source.

According to Yip (2021), in primary healthcare settings, SCDNT provides as an adequate theoretical framework for nursing practice. By putting the SCDNT's principles into practice, primary care nurses may provide care for a person as an integral part of a larger family and society. The case study that was used in this study showed how the SCDNT could help an APN see their patient as a person who can acquire, develop, and adopt a self-care routine. APNs can use nurse-sensitive measures to assess their clinical practice as one practical result of employing the SCDNT. Orem's theory helps us better comprehend the continual fluidity and adaptation of advanced nursing practice and basic healthcare by providing a useful framework for reflection on patient care.

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

Friesen, M. A., Brady, J. M., Milligan, R., & Christensen, P. (2017). Findings From a Pilot Study: Bringing Evidence-Based Practice to the Bedside. Worldviews on evidence-based nursing, 14(1), 22–34. https://doi.org/10.1111/wvn.12195 Comment by Ginger King: Replace this with the seminal source.

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.

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

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-egineered 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/10.1097JHQ.0000000000000266

Healthcare facilities are being compelled by a number of factors to enhance their discharge procedures in order to decrease readmissions. The Re-Engineered Discharge was created and tested by researchers at the Boston University Medical Center (BUMC) with the goal of enhancing the discharge procedure (RED). According to research, the RED proved successful in lowering post hospital ED visits and readmissions. This toolkit was created under a contract between the Agency for Healthcare Research and Quality (AHRQ) and BUMC to help healthcare facilities, especially those that serve diverse populations, replicate the RED. The RED is made up of a group of 12 interconnected tasks that the hospital completes both during and after the patient's stay to ensure a successful discharge (AHRQ, 2020).