PROJECT 2 - OLGA
Gracenana
Project1correctionsneeded.docxReducing the Rate of Readmission Rates Aamong Diabetic Patients By uUsing a Transition of Care Protocol in Case Management and Care Coordination in a Managed Care Organization
George Olga
Boston University
DNP 761: DNP Project I
In partial fulfillment of the requirements for the Doctor of Nursing Practice
DNP Project Chair: Denise DNP, RN, ACUE, WCC Comment by Tracey Johnson-Glover: Dr. Denise Zabriskie Dr. Tracey Johnson-Glover
DNP Project Team Members: Dr. Tracey DNP, RN
April 18, 2021
Reducing the Rate of Readmission Rates Among Diabetic Patients Using a Transition of Care -Protocol in Case Management and Care Coordination in Managed Care Organization Comment by Denise Zabriskie: This title should be on a separate page.
Diabetes is considered one of the major chronic illnesses associated with high rates of hospitalization. This condition can complicate the discharge process and the transition of patients back into the community. Diabetes is a condition that affects all age groups but however, individuals who are over 65 years old are at a higher risk (Butalia, 2020). Diabetes is associated with high rates of readmission within 30 after a patient isof being discharged from a hospital. Nearly one out of every five diabetic patients, representing about approximately 2.6 million people, are readmitted within 30 days of discharge (Duke et al., 2013). Transition of care (TOC) is defined as the movement of a patient from one care setting to another care setting. Increased risk of health complications is associated with the transfer of patients diagnosed with diabetes mellitus (DM) from one setting to another (Duke et al., 2013). Harkness (2020) reports that the causes of the complications are attributed to miscommunication between the settings and the ability to meet the needs of the patient at the new healthcare setting. Transition of care (TOC) is defined as the movement of a patient from one care setting to another care setting. The TOC model is often performed when discharging a patient. It The TOC model is a complex process that requires the collaboration of the case management and care coordination departments to ensure safe transitioning of the patient. Therefore, this Doctor of Nursing Practice (DNP) project will address the reduction of readmission rates for patients diagnosed with diabetes mellitus (DM) by using a TOC model in managed care. The project lead will focus the use of the TOC model in the case management and care coordination departments of a managed care organization. Comment by Tracey Johnson-Glover: Is it miscommunication between the settings or providers? Comment by Denise Zabriskie: Please don’t use the word it in an academic paper when referring to the topic Comment by Denise Zabriskie: I think you need one statement that is supported by evidence that the TOC model has been successful.
Background
Also, TOC ensures that caregivers at the community settings are provided with appropriate information regarding patient’s health status as well as the measures to take to make sure that the patient is well-cared for at home. A patient is vulnerable to adverse events during the movement of a patient (Harkness, 2020). Comment by Denise Zabriskie: All this can go in the background
The United States (US)of America is experiencing a growing burden of DM infections.”It is estimated that 9.3% of the American population, representing about approximately 30 million people, are diagnosed with DM while 28% are not diagnosed. Among hospitalized patients, 25% of them have diabetes” (Rains, 2020). Patients diagnosed with DM are more likely, than those without DM, to be readmitted with other complications such as heart failure, cardiac surgery, and myocardial infarction. DM is associated with a readmission rate of 14-22%, which is higher than the rate for all hospitalized patients that is estimated to be 8.5-13.5% (Rains, 2020). DM is a costly disease; the direct medical cost is approximately $218 billion per year with an additional indirect expenditure of $46 billion per year. A significant contribution to these expenditures is the readmission cases. Comment by Denise Zabriskie: I don’t think DM is considered an infection. I recommend deleting this statement Comment by Denise Zabriskie: Citation needed Comment by Denise Zabriskie: Spell out the words when used at the beginning of the sentence. Comment by Denise Zabriskie: Citation needed
TOC Transition of Care for the diabetic patient is associated with problems that hinder positive patient outcomes and thus increase the readmission rates of patients due to factors such as patients notnon adhering to prescribed medications, and lack of education on in injecting insulin, self-care measures, and healthy nutrition. Garnica (2017) reports that high readmission rates among DM patients are caused by unclear discharge processes where there is no consultation provided by the care coordination departments, improper coordination between the care provider and the caregiver at home, a lack of resources in the community setting, the inability of the patient to manage self-care, and a low level of health literacy of the patient and the caregiver at home. When a patient is being discharged from the inpatient setting to the community, there are cases of poor care coordination that can occur between the inpatient and outpatient setting (Harkness, 2020). These events include lapses of communication between care providers in the inpatient and outpatient settings and include: medication changes that may be intentional or unintentional, diagnostic work-ups that have not been completed when the patient is discharged, a lack of understanding of the diagnoses between the caregiver, patient, and care provider, inadequate patient comprehension of medications, and the insufficient coordination of the patients’ follow-up needs at the time they are discharged (Price, 2021). It is tTherefore, it is necessary to create TOC protocols utilizing the TOC model as a framework to ensure that there guidelines being followed during the discharge process improve the transition process. Creating a TOC protocol will guide the discharge process to ensure proper communication between the two settings (Duke et al., 2013). A well- formulated TOC protocol is a multidisciplinary approach to provide discharging a patient diagnosed with DM to ensure a better patient understanding of discharge instructions and offer social services to provide the resources needed for quality home care thusto reducinge the rate of readmission. This Doctor of Nursing Practice (DNP) project will improve hospital readmission rates among patients diagnosed with DM by incorporating the TOC model into a multidisciplinary approach to the discharge process in a managed care setting . The TOC model ensures that caregivers at the community settings are provided with appropriate information regarding patient’s health status as well as the measures to ensure the patient is well-cared for at home. A patient is most vulnerable to adverse events during the transition from the hospital to home (Harkness, 2020). Comment by Tracey Johnson-Glover: Nonadherence
Background
High readmission rates among patients with diabetes is associated with various factors regarding the patient TOC from a hospital to the community . Garnica (2017) reports that high readmission rates among DM patients are caused by unclear discharge processes where there is no consultation provided by the care coordination departments, improper coordination between the care provider and the caregiver at home, a lack of resources in the community setting, the inability of the patient to manage self-care, and a low level of health literacy of the patient and the caregiver at home. When a patient is being discharged from the inpatient setting to the community, there are cases of poor care coordination that can occur between the inpatient and outpatient setting (Harkness, 2020). These events include lapses of communication between care providers in the inpatient and outpatient settings and include: medication changes that may be intentional or unintentional, diagnostic work-ups that have not been completed when the patient is discharged, a lack of understanding of the diagnoses between the caregiver, patient, and care provider, inadequate patient comprehension of medications, and the insufficient coordination of the patients’ follow-up needs at the time they are discharged (Price, 2021).
Lack of care coordination and poor TOC protocols costs the healthcare system approximately $46 billion a year (Harkness, 2020). The hospitalization of patients and their stays in health care facilities costs the United States (US) approximately $378 billion every yearannually and readmission due to lack of TOC leads to an increase in the length of stay for patients in care settings (Vandensande, 2020). Readmission due to lack of TOC leads to an increase in the length of stay for patients in care settings, which further increases the financial burden. This has resulted in increased pressure for managed care organizations to improve care coordination and in order to reduce the risks faced by patients during TOC. Therefore, to help in the reduction of the rate of readmission and reduce the cost of health care services for patients suffering diagnosed withfrom diabetesDM, it is important for case management and care coordination departments to work together to create implement TOC protocols to ensure positive outcomes and improvements in quality of care. A protocol focusing on TOC for diabetes patients is proposed. The project proposal aims to reduce the rate of readmission and healthcare costs associated with DM by implementing a protocol to assist in TOC. The protocol will include patient and family education, which assists in understanding the management procedures for self-care (Grady et al., 2021) as well as Comment by Denise Zabriskie: This does not really fit here Comment by Tracey Johnson-Glover: To reduce the rate of readmission and decrease the cost of health….. Comment by Denise Zabriskie: This will come in later in the paper. Recommend deleting here and saving this for later Comment by Tracey Johnson-Glover: ???
Problem Statement
TOC for patients suffering from diabetes is a process that can result in high cost from high rates of readmission after poor coordination of care during patients’ transition between healthcare settings. Readmissions and associated costs could be prevented by implementing an appropriate discharge process TOC protocol in the case management and care coordination department,. There is a need to create a TOC protocol in the case management and care coordination departments to help which would address the gaps that exist in the current interdisciplinary discharge process. Comment by Denise Zabriskie: You have to spell out the words in the beginning of the sentence Comment by Denise Zabriskie: This statement is awkward, I recommend deleting it
In the current practice, there is a rising burden in the management of diabetes, which is exacerbated by the rising rate of readmission;14% of DM patients are readmitted within 30 days (Rains, 2020). The high rate of readmission is due to the lack of a TOC protocol where patients are discharged upon attaining the health objectives set in the inpatient setting. When patients are discharged, there is a lack of proper guidelines that are to be followed to ensure that a patient is fully equipped and ready for self-care in the community setting after discharge. This leads to many patients being readmitted to the healthcare facility due to various complications associated with diabetesDM. Readmission rates influence the cost of healthcare as it leads additional expenditures in the provision of care to DM patients, and it is estimated that the readmission cases cost the healthcare industry approximately $46 billion every year (Shillington & McNeil, 2021). These costs can be reduced through the creation of a TOC protocol where patients are evaluated and assessed to ensure that they are ready to be discharged. Readiness to discharge a DM patient can be assessed by the case manager and care coordinator by evaluating the available resources for self-care, comprehension of the patient and family members on the measures to take when attending to patients, and the literacy of patient and caregivers in the community setting. These can be enhanced through patient and family education where the care provider can educate patients and caregivers on various aspects of self-care. Comment by Denise Zabriskie: This is repetitive Comment by Denise Zabriskie: This section should be brief. Please tie this to the project site. For instance, currently the project site does not utilize the TOC model framework in the discharge process, which is causing increased readmission rates within 30 days of discharge. Does this cause penalties or a reduce reimbursement from CMS?
PICOT Question
In case managers and care coordinators (P), how does the use of a TOC protocol (I) compared to the current practice without TOC protocol (C) reduce the readmission rates, improve self-care, and improve at home quality care for diabetic patients diagnosed with DM (O) within 4-5 weeks (T)? Comment by Tracey Johnson-Glover: Does the use of a TOC protocol
References Comment by Denise Zabriskie: References should be on its own page. Please use double spacing per APA
Butalia, S., McGuire, K. A., Dyjur, D., Mercer, J., & Pacaud, D. (2020). Youth with diabetes and their parents' perspectives on transition care from pediatric to adult diabetes care services: A qualitative study. Health Science Reports, 3(3), e181.
Duke, D. C., Raymond, J. K., Shimomaeda, L., & Harris, M. A. (2013). Recommendations for transition from pediatric to adult diabetes care: Patients’ perspectives. Diabetes Management, 3(4), 297-304. https://doi.org/10.2217/dmt.13.26
Garnica, P. (2017). Transition of care for patients with diabetes. Current Diabetes Reviews, 13(3), 263-279. https://doi.org/10.2174/1573399813666161123104407
Grady, K. L., Rehm, R., & Betz, C. L. (2021). Understanding the phenomenon of health care transition: Theoretical underpinnings, exemplars of nursing contributions, and research implications. Journal of Pediatric Health Care. https://doi.org/10.1016/j.pedhc.2020.12.003
Harkness, T. L. (2020). Effective care coordination and transition management for older adults. Nursing Made Incredibly Easy! 18(5), 26-32. https://doi.org/10.1097/01.nme.0000694184.27758.b9
Price, A. M. (2021). Ethics in critical care research: Scratching the surface. Intensive and Critical Care Nursing, 103013. https://doi.org/10.1016/j.iccn.2021.103013
Rains, M. (2020). Improving patient care and reducing readmissions using a standardized transition of care plan. Heart & Lung, 49(2), 214. https://doi.org/10.1016/j.hrtlng.2020.02.018
Shillington, J., & McNeil, D. (2021). Transition from the neonatal intensive care unit to home. Advances in Neonatal Care, Publish Ahead of Print. https://doi.org/10.1097/anc.0000000000000835
Vandensande, T. (2020). Starting the transition towards integrated community care 4all. International Journal of Integrated Care, 20(2). https://doi.org/10.5334/ijic.5553
