Stakeholders will ensure that important information is delivered appropriately and promote smooth implementation of the project (Harris, Roussel, Walters, & Dearman, 2011). The key stakeholders will include individuals with an interest in the project outcome. They will include the hospital executives based on Value-Based Purchasing (VBP) standards and financial implications for CMS reimbursement; cardiologists who can provide professional assessment; Advanced Practice Nurses who can oversee the clinical transition of care for the HF population; case management and social work professionals; and family members who will get post-discharge instructions.
Assessment of the environment
A comprehensive assessment of the environment will not only reveal the real policies and difficulties that affect the intervention but also identify appropriate ways of supporting this project.
The SWOT analysis results will enable the project manager to perceive the relationship between vulnerability issues and favorable factors that will enhance the success of this project.
- Motivated healthcare professionals in the acute healthcare system
- Receptive and willing participants (Elderly HF patients)
- Structures for acute care for HF patients
- Facilities for social support and leisure
- Social exclusion of the HF patients due to advanced age and medical condition
- Low economic capacity
- Low levels of literacy on HF self-care
- Limited independence of HF patients/complete dependence
- Lack of health intervention strategies to promote the health of HF patients
- Inadequate evaluation of HF patients prior to discharge
- Improved life expectancy
- Collaborations and partnerships in the healthcare sector
- Integration of social work and case management into transitional care
- Existence of the cardiac and intensive care unit in the hospital
- High levels of dependence among the elderly
- Low commitment to elderly care by family
- Unhealthy practices
A gap analysis will help identify the discrepancies between the present model employed in the hospital and clarify the opportunities that the teach-back model will address (Hall, & Roussel, 2013). This will help define the health objective of the intervention. A gap analysis can effectively uncover opportunities available for improvement. The first step is to understand how the current HF care model is working (or not working) by examining its processes to determine weaknesses or broken links. It is clear that the problem is the lack of collaboration between the different healthcare professionals. HF care requires a multidisciplinary healthcare team to help in the management of patient symptoms. The health care team should consist of a cardiologist, a case manager, a dietitian, and a social worker. Patients should be taught how to identify subtle HF symptoms and inform the healthcare professionals to manage them and reduce readmissions.
Heart failure is a common disease among the elderly that has the highest readmission rates. A proper care transition will ensure better symptom management through pharmaceutical interventions, surgical interventions, and lifestyle changes to slow down HF progression. It facilitates implementations of evidence-based interventions such as comprehensive assessment on admission; post-discharge follow-ups; and proper transition to home to reduce the rate of hospital readmissions.
Nevertheless, literature reviews and surveys have shown that there is sub-optimal use of these interventions as HF readmissions are still high. In relation to this hospital, the major gaps identified include; (1) inadequate capacity for patient care management at home settings; (2) inadequate assessment of the patient, often the physician does receive all the patient information on admission; (3) inadequate guidelines on follow-ups leading to more readmissions; and (4) lack of capacity to address HF patients’ care needs at a convenient place and time, which forces patients, for fear of their safety, to seek readmission.
In this project, the proposed methodology, the teach-back model, will emphasize the coordination of patient care. Given the complex nature of HF care, this model will ensure individualized patient care through self-care and patient education to decrease readmissions.
As patients are discharged to home-based care, there must be continuity of care. The five Ps can help to streamline case management for HF patients and seal broken links in care delivery (Smith et al., 2010). The five Ps include patient, plan, purpose, problems, and precautions. The patient information including bio-data like name, age, gender, address, and occupation should be made available to case managers and social work professionals. The plan comprises patient diagnosis, the care plan for the specific patient, and the recommended steps for case management. The purpose refers to the aim of the proposed care plan, which in this case is to reduce hospital readmissions. The problems describe the challenges faced in CHF treatment while precautions explain how the proposed intervention will be different from the current practice.
The Institute of Medicine (IOM) identifies fundamental aims of assessment of the environment to determine the effectiveness of an intervention. The aims include; (1) to enable the HF patients to manage the condition through the proper transition to home after discharge. This can be achieved through several interventions including educational programs like the teach-back method. Another IOM aim is to ensure safe hospital discharge of the patient and ensure improved lifestyle through better symptom management. The project will achieve this through case management and post-discharge follow-ups. The third IOM aim is to promote the effectiveness of the intervention to reduce readmissions. The project aims to achieve improved patient outcomes through timely teaching and comprehensive skills and knowledge assessment to determine the patient’s capacity to identify and manage HF symptoms. The other IOM aim is to promote addressing the problem using a patient-centered approach rather than focusing on the disease. This involves the teaching of patients on symptom management according to the severity of their condition and the level of their skills and knowledge.
Root Cause Analysis
The surveys and literature identified different factors that lead to high readmission rates among HF patients. These include failure to take medication as prescribed, limited family participation and support, poor dietary habits and lifestyles, failure to attend appointments, and inadequate knowledge of symptom management. Based on these findings, measures on symptom management should be explained clearly to the patient. Also, hospital staff including case managers and social work professionals should educate the patient on dietary restrictions, lifestyle changes, and healthy behaviors. The results of this root cause analysis emphasize the importance of seamless continuity of care involving hospital staff (hospital executives, cardiologists, APNs, case managers) and social work professionals, and family/community members. Coordination of the different stakeholders in the proposed project will lead to an improvement in self-care for patients with heart failure and decrease hospital readmissions.
Hard Core Data
Congestive heart failure (CHF) is one of the leading causes of hospital readmissions, which is very costly to providers. It is estimated, in the United States alone, CHF affects close to 6.5 elderly people and, if unchecked, its prevalence is projected to continue rising (Boren, Wakefield, Gunlock & Wakefield, 2009). It is further estimated that insurers spend up to $8,000 per patient annually due to repeated admissions (Smith et al., 2010). In 2004 alone, the annual cost of hospital readmissions was a staggering $17.4 billion (Aliti et al., 2007). Given the complex chronic conditions associated with CHF, patients are frequently readmitted to hospitals for specialized care making CHF one of the major causes of costly hospital readmissions.
The frequent readmissions, despite improvements in CHF symptom management, lead to higher hospital costs. It is estimated that the annual financial costs to Medicare are a staggering $38 billion (White, Garbez, Carroll, Brinker, & Howie-Esquivel, 2013). CHF is diagnosed among the elderly (65 years and above) and requires complex care due to associated co-morbidities. The rising number of elderly people diagnosed with CHF means that the healthcare sector has to implement strategies to decrease these costs. Hospital readmissions could be reduced through a teach-back method, which enhances patient self-care through patient education (White et al., 2013). This can begin during admission and extend well into the post-discharge care environment. Pre-discharge education has been shown to decrease the rate of hospital readmissions.
Developing the Strategy
New strategies for CHF management have been proposed in the recent past aimed at reducing the high cost of readmissions. Heart failure management strategies focus on symptom management. The best strategies that have been found to achieve increased patient outcomes include; proper transition to the home environment, post-discharge care, and comprehensive assessment of patients on admission (Aliti et al., 2007). However, many heart failure management interventions have not resulted in a consistent decline in readmission rates (Aliti et al., 2007). Thus, new management interventions are needed to enhance the health outcomes of CF patients.
Research evidence has shown that patient education on HF medication, medication side effects, and early recognition of CHF symptoms is positively correlated to reduced readmissions. The teach-back method focuses on the patient as a holistic individual instead of symptom management alone (Annema, Luttik, & Jaarsma, 2009). The model emphasizes the need for collaboration and coordination of care services. Through this model, the complex physical, financial and social needs of the patient are addressed through individualized education. Thus, chronic conditions and symptoms can be addressed in the home setting and avoid unnecessary readmissions.
In the recent past, there have been increased efforts to reduce the hospital readmissions associated with heart failure. The high rates of readmission have contributed to high health care costs incurred by the healthcare industry. This proposed project will examine the correlation between an intervention (teach-back method), hospital readmissions, and patient health outcomes.
CHF is a chronic condition that requires acute care. Case managers can play a crucial role in helping a patient with heart failure to learn essential skills for independent disease management. They can facilitate disease education, symptom management and coordinate care delivery for such a patient. The Teach-back method is an interactive learning approach to enhance self-care among HF patients. Through constant monitoring, subtle signs and symptoms can be identified and managed before they can lead to readmission of the patient. The proposed project will assess the effectiveness of the teach-back method on patient outcomes and reduce hospital readmissions.
Aliti, G. B., Rabelo, E. R., Domingues, F. B., & Clauseil, N. (2007). Educational settings In the management of patients with heart failure. Rev Latino-am Enfermagem, 15(2), 344-349.
Annema, C., Luttik, M. L., & Jaarsma, T. (2009). Do patients with heart failure need a case manager? Journal of Cardiovascular Nursing, 24(2), 127-131.
Boren, S. A., Wakefield, B.J., Gunlock, T.L., & Wakefield, D. S. (2009). Heart failure self-management education: A systematic review of the evidence. International Journal Evidenced Based Healthcare, 7(1), 159-158.
Hall, H. & Roussel, L. (2013). Evidence-based practice, an integrative approach to research, administration, and practice. Sudbury, MA: Jones & Bartlett Learning.
Harris, J.L., Roussel, L, Walters, S.E., & Dearman, C. (2011) Project planning and management, a guide for CNL’s DNP’s and nurse executives. Sudbury, MA: Jones and Bartlett Learning.
Smith, D. H., Johnson, E. S., Thorp, M. L., Crispell, K. A., Yang, X., & Petrik, A. F. (2010). Integrating clinical trial findings into practice through risk stratification: The case of heart failure management. Population Health Management, 13(3), 123-129.
White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquibel, J. (2013). Is “teach back” associated with knowledge retention and hospital readmissions in hospitalized heart failure patients? Journal of Cardiovascular Nursing, 28(4), 137-146.