hospital readmissions arising
Running Head: IMPLEMENTATION 1
IMPLEMENTATION 6
Phase 3-Implementation
Institutional Affiliation
Student Name
Owing to the increasing rates of hospital readmissions arising from poor transitional care it is essential to implement a program that will see to it that the current challenges facing transitional care are addressed and that there is an increase in specialized nursing to help foster the provision of transitional care. Currently, the health care committee has proposed a number of interventions that need to be implemented by the project manager to see the improvement of transition care, especially in relation to dealing with elderly patients (Morphet et. al., 2014). Some of these interventions that have been proven to result in the reduction of patient readmission rates among them patient needs assessment, patient education, medication reconciliation, timely outpatient appointment as well as the provision of telephone follow-up services (Morphet et. al., 2014).It is essential that once the patients are discharged from hospitals that they continue to receive enhanced communication, medication safety and that their caregivers receive advanced care planning and training on how to best manage the associated common medical conditions (Ortiz, 2019). As a result of the currently proposed interventions, the project aims to target the challenges on transition care by defining the role of home-based services, the significance of caregiver support, community partnerships and the importance of new transitional care personnel (Ortiz, 2019). The project manager has gone as far as proposing the time frame that it will take to see the realization of the effects of the project, a practical budget as well as the resources and tools that will be used in the project to see the successful realization of the transitional care program.
The Time Frame of the Project
| ACTIVITIES | TIMELINE |
| Ascertaining the current state of Transitional Care in Hospitals (Patients Admissions, Level of Communication and Coordination among the Nurses, Level of Interaction between the Healthcare providers and the Nurses) | 6 months |
| Ascertaining the Level of Nursing Expertise in Hospitals (Level of Education and Expertise of the Nurses) | 6 Months |
| Making Home Visits to the Patients to Ascertain the Level of Expertise of the Caregivers | 6 Months |
| Consolidation of the Collected Results | 6 Months |
The enactment of the transitional care program includes the inclusion of a defined timeline on how the different roles will be attained. Going by the evaluations by the project manager, the planned timeline that it will take to achieve concrete improvements includes having six scheduled visits to the hospitals for two years. The two-year time frame includes a close working relationship with elderly patients, health care providers, as well as the patient caregivers, all of whom are key stakeholders in the transitional care process. The first six months of the proposed time frame will include the use of the observation method to ascertain the current state of transitional care in the hospitals. In this time frame, notes will be taken on how the parents are received in the hospitals, their admission to the emergency departments, the communication and coordination of the nurses when dealing with the elderly patients, as well as the level of interaction between the caregivers and the health care providers in the event that the patients are released from hospitals.
The second half of the first year will be solely used to ascertain the level of nursing expertise in regards to transitional care. Past studies, as well as the Masters’ Essentials, have ascertained that the use of unspecialized nurses remains to be one of the key challenges facing the provision of health care services. Additionally, previous observations and studies have established that there remains to be a significant difference in the provision of services given by masters-level nurses and those below the master’s level unit. Hence, the six-month-time-frame will be used to interact with the nurses providing transitional care, to determine their level of education and training as well as their experience when it comes to the provision of transitional care. Additionally, the observation method will come in handy to observe the differences in the provision of services by both the specialized and unspecialized nurses.
The next six months of the second year will be used to make visits to the patient homes, to determine the level of expertise held by the caregivers in relation to caring for the patients as soon as they are discharged from the hospitals. The key activities in this allocated time will involve holding conversations as well as interviews with the caregivers to ascertain their level of preparedness, education, and expertise in relation to taking care of the patients as a means to reduce the high rates of hospital readmissions. Additionally, the time frame will be used to observe how the patients respond to the care provided by their caregivers, as well as their level of comfort and how fast their get back to their health as soon as they are discharged.
The last six months of the allocated time-frame will be used to consolidate the different results collected and to revisit areas with inadequate information as a means to eliminate any existing biases or inconsistencies in the results. Therefore, the allocated two-year time-frame for the project will be adequate to see to it that all the existing challenges in transitional care are adequately addressed.
Budget for the Project
