Poster Presentation

The delivery of individualized care is important in ensuring receipt of optimal benefits of care rendered to patients. Discharged patients should be released to community agencies that provide in-home assistive services. The transition plan must consider the patient's home environment as well as the risks for injury and find ways of mitigating them as soon as possible. Service providers should take advantage of family conferences to advise the patients’ family of how to care for the patient after they have been discharged from the hospital. Hence, there is a need for post-discharge follow-up especially for high-risk patients, to deter readmission rates (Potera, 2009).

This paper aims to discuss methods of monitoring solution implementation; evaluate the solution; and lastly, tackle outcome measures and data collection evaluation.

Monitoring

Monitoring is a scheduled collection and analysis of data so as to track the progress of the implemented solution and ensure that the solution is in compliance with the set health standard regarding patient discharge (Popejoy, L.L., et al., 2015). Monitoring is a critical aspect of any implementation process since it helps in establishing patterns and coming up with strategies for proper management and quality improvement. Monitoring and evaluation in the health care sector are paramount in ensuring quality services. It is critical to monitor the implemented solutions for the issues affecting patient-centered care and discharge planning (Potera, 2009).

The Stetler Model assists in the monitoring of the solution using its steps. “The monitoring consists of preparation, validation, decision-making, application and finally evaluation according to the steps of the Stetler Model (Stetler, 2001).” The preparation for monitoring begins with the purpose; sources of the evidence of the research; and then the context of health care. The identification of purpose depends on the solution proposed. Therefore, the contextual factors must be examined to determine the appropriate monitoring strategy.

The second phase is the validation of the monitoring process. The solution identified was for the IDT to ensure that patients receive individualized care, which are carried out post hospitalization and prevent patients returning to the hospital. Therefore, the patient-centered care and reduction of readmission would be the ultimate goal of monitoring. The monitoring process starts with the formulation of healthcare providers with unified policy-driven structure ensuring that there are proper communication and coordination and culminates with patient being released in the community.

Evaluation

All the IDT will be involved in the designing as well as the implementation of the program. Stakeholders are expected to obtain and report their expertise, perspectives and feedback. The next step will be clarifying the scope of the solution plan. In this case, the scope would entail defining the purpose as well as evaluating other aspects of the program as the budget and the target clientele. The second step will entail developing questions, which will be addressed based on outcome solutions, after which it would be viable to develop indicators of change and performance. The third step is developing the questions that the program is intended to answer. After developing questions comes along the selection of relevant indicators. Indicators are useful mechanisms for measuring achievements, as well as reflect any changes in the program. Following the selection of the indicators is deciding on the viable methods of data collection. Data collection method can be qualitative or quantitative approach. Once data is collected, analysing of data collected comes into play. Final step would be communicating the findings, insights, and recommendations to the stakeholders.

Outcome measures. “Patient-reported outcomes measures (PROMs) are an important component of assessing as well as evaluating whether clinicians are improving the health of patients. Unlike process measures, that assist in capturing provider productivity and adherence to the patient experience measures, or standards of recommended care which focus on aspects of care delivery such as communication, the PROMs seeks to measure whether the services provided improved patients' health and sense of well-being (Black, 2013).” The outcomes measures determine whether the process implementation is successful or not. The outcomes measures include the following:

· The understanding of the discharge process that starts from the admission of the patient.

· The effectiveness of unified policy-driven structure that would ensure that there are coordination and proper communication amongst different health care providers.

· The number of community agencies that provide in-home assistive service

· The impact of home environment on the risk of injury.

· The ways to find mitigating strategies to reduce the risk of injury to the discharged patient.

· The service provider should take advantage of the family conferences to advise the patients’ family of how to care for the patient after they have been discharged from the hospital.

· The facilitation of post-discharge follow-up especially for high-risk patients, to deter readmission rates.

Evaluation Data Collection . The ways to deal with estimation is useful to make a qualification amongst quantitative and subjective techniques. Reviews utilizing organized surveys are the most widely recognized type of quantitative measures of patients' experience (Petitti, D.B., et al., 2000). These are intended to create numerical information that can be examined measurably and used to portray and think about results from the example populace all in all and particular sub-bunches. The accentuation is on analyzing examples and patterns from a vast specimen, giving broadness and the capacity to look at, however regularly inadequate with regards to profundity since inquiries and reaction alternatives foreordained.

The accompanying quantitative techniques and advancements for acquiring tolerant criticism (Petitti, D.B., et al., 2000):

· self-consummation postal studies

· Interviewer-managed vis-à-vis studies

· telephone reviews utilizing live questioners

· automated phone reviews (intuitive voice reaction – IVR)

· online reviews utilizing electronic or email polls

· surveys utilizing compact hand-held gadgets (PDAs or tablets) (on location)

· surveys on touch-screen booths (on location)

· surveys on bedside comforts (nearby)

· Administrative information/routine measurements.

Qualitative techniques are diverse in that the attention is on acquiring an inside and out comprehension of individual encounters and the way they clarify or decipher these (Black, 2013). Subjective information is typically reported utilizing words, not numbers, and it is harder to utilize the confirmation to make examinations or speculations. Some subjective techniques that would be utilized incorporates (Black, 2013):

· in-profundity eye to eye meetings (might be sound or recorded)

· Discovery interviews completed by clinical staff

· Focus group

· web-based free content remarks

· comment cards or proposal boxes (nearby)

· Complaints and compliments

· Patient journals

Conclusion

It is important for clinicians to be aware on the goals of patient-centered care and discharge planning to ensure understanding that care process starts from patient’s admission. It is also crucial to set up a unified policy-driven structure that will ensure coordination and proper communication among different health care providers in regards to patients’ plan of care. This paper discussed methods of monitoring solution implementation; evaluation of solution; and lastly, tackled outcome measures and data collection evaluation.

References

Black, N. (2013). Patient reported outcome measures could help transform healthcare. BMJ (Clinical Research Ed.), 346, f167.

Petitti, D. B., Contreras, R., Ziel, F. H., Dudl, J., Domurat, E. S., & Hyatt, J. A. (2000). Evaluation of the effect of performance monitoring and feedback on care process, utilization, and outcome. Diabetes Care, 23(2), 192-196. doi:10.2337/diacare.23.2.192

Popejoy, L. L., Jaddoo, J., Sherman, J., Howk, C., Nguyen, R., & Parker, J. C. (2015). Monitoring resource utilization in a health care coordination program. Professional Case Management, 20(6), 310-320. doi:10.1097/NCM.0000000000000120

Potera, C. (2009). Lowering hospital readmissions and costs. The American Journal of Nursing

Stetler, C. B. (2001). Updating the stetler model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49(6), 272-279. doi:10.1067/mno.2001.120517