Digital Repository Masters Projects Spring 2023 Improving Discharge Readiness to Decrease Readmission Risk Danielle Nay Richins Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Richins, D. N. 2023. Improving discharge readiness to decrease readmission risk. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Improving Discharge Readiness to Decrease Readmission Risk Project Title by Danielle Nay Richins Student’s Name $ SURMHFW VXEPLWWHG LQ SDUWLDO IXO¿OOPHQW RI WKH UHTXLUHPHQWV IRU WKH GHJUHH RI 0$67(56 OF NURSING $QQLH 7D\ORU 'HH 6FKRRO RI 1XUVLQJ 'XPNH &ROOHJH RI +HDOWK 3URIHVVLRQV WEBER STATE UNIVERSITY 2JGHQ 87 March 26th, 2023 Date Danielle Nay Richins, BSN, RN, MSN Student 3/26/2023 6WXGHQW 1DPH &UHGHQWLDOV Date (electronic signature) 4/5/23 061 3URMHFW )DFXOW\ (electronic signature) Date 05/25/2023 0HOLVVD 1H9LOOH 1RUWRQ (electronic signature) '13 $351 &313 3& &1( *UDGXDWH 3URJUDPV 'LUHFWRU Note: The program director must submit this form and paper. Date 1 Improving Discharge Readiness to Decrease Readmission Risk Danielle Nay, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing 2 Abstract Preventable readmissions can occur due to a lack of patient education, preparation, and support and can be costly to hospitals and patients. Evidence indicates that follow-up phone calls and using transition coaches can reduce unnecessary readmissions and improve patient outcomes. The early identification of patient-specific needs and learning barriers can support quality patient care and reduce the likelihood of readmission. Additionally, including the caregiver throughout the discharge process is essential for preparing patients to self-manage diseases at home. This project aims to reduce readmission rates through optimal patient education, discharge planning, and support through the transition from hospital to home. This project will include educational resources for nurses stepping into the transition coach role, a readmission risk health needs assessment, and additional templates for identifying the required transitional care services. These resources will prepare nurses to support patients through discharge to decrease unnecessary readmissions and associated costs. Keywords: readmission rates, discharge planning, transition coach, follow-up phone call, readmission risk health needs assessment, transitional care services, discharge process. 3 Improving Discharge Readiness to Decrease Readmission Risk Nurses have many patient-care tasks that they are required to perform. Preparing hospitalized patients to manage their health conditions after discharge should be a nursing priority. Providing high-quality, individualized discharge plans and follow-up communication is essential because this can help prevent adverse outcomes and hospital readmissions (Hayajneh et al., 2020). Poor health outcomes and unnecessary readmissions occur when the patient is not adequately prepared and supported throughout the discharge process (Flink & Ekstedt, 2017). Discharge teaching can make or break a patient's preparation to go home and return to their everyday life. Current discharge preparation includes providing information about why the patient was hospitalized and the interventions they received while there. Unfortunately, nurses do not always teach patients self-management tasks and lifestyle adjustments to help them succeed when they go home (Flink & Ekstedt, 2017). Increasing discharge preparedness, education, and resources for patients discharged from acute care hospitals can decrease readmission risks (Flink & Ekstedt, 2017). Research shows that for patients with complex needs, effective collaboration, family inclusion, communication between healthcare workers and families, and ongoing support after discharge are essential for positive health outcomes (Emes et al., 2018). Although this is true, nurses do not always plan the pace of patient education far enough in advance (Thum et al., 2022). In addition, this lack of planning can lead to rushed education sessions and fragmented discharge plans, resulting in patients and their caregivers feeling unprepared to continue their recovery at home. Statement of Problem 4 Early, individualized discharge planning is essential for nurses to perform when preparing a patient to transition home (Thum et al., 2022). Discharge planning is a process that begins at admission and sets the foundation for an individual's ability to successfully self-manage diseases at home by providing them with support and resources to help them through the process (Hayajneh, 2020). Although this is critical, many patients leave the hospital unprepared to manage their diseases at home without the help of medical professionals. In addition, poor discharge planning leads to preventable readmissions that could have been avoided had they received proper education and support in the hospital (Flink & Ekstedt, 2017). The purpose of this project is to improve the discharge processes in an acute care hospital to reduce the number of preventable hospital readmissions. This goal will be accomplished by implementing an early individualized patient discharge plan through transition coaches. The coach’s focus will be to better prepare patients for disease self-management at home through enhanced education in the hospital. Ways Project Contributes to Intended Recipients This change will benefit patients, caregivers, and nurses. This project can benefit patients by improving their transition from hospital to home. Creating individualized discharge plans that address each patient's needs ensures that the proper education and resources are provided to aid them in managing their diseases once they are home (Flink & Ekstedt, 2017). The transition of patients from hospital to home must be individualized and multifaceted to meet the needs of each patient (Ryan et al., 2019). One universal plan is not suitable to meet each patient's unique needs. Improving education so patients can learn to self-manage their diseases at home is critical, and nurses play an essential role in that education (Ryan et al., 2019). Implementing transition nurses can also support the patient through the transition from hospital to home. Components of 5 transitional care programs that improve patient outcomes include patient education, telephone follow-up, early assessment after hospital admission, including caregivers, home visits, and communication during the handoff to post-discharge providers (Ryan et al., 2019). Transition nurses are key players in helping patients through all the steps of the discharge process. This project can also benefit patient caregivers by providing better education and preparation for helping the patient recover once home. Including the caregiver in education sessions prior to discharge can help caregivers feel more confident in their ability to help patients self-manage diseases once at home (Mitchell et al., 2018). Discharge preparation should include improved access to community resources and support around them once discharged (Welch et al., 2018). Caregivers impact patients' ability to understand and adhere to their discharge instructions. When they are present and involved during planning and education sessions, they are better prepared to support the patient through the transition home (Hahn-Goldberg et al., 2018). Nurses also benefit from this change as it allows them to take on a new role in educating and preparing patients to manage their diseases at home as transitional coaches. Much of this education includes how to use lifestyle changes to improve health (Hoyer et al., 2018). In addition, the transition coaches can aid patients throughout the discharge process and interact more closely with them after discharge to coordinate follow-up care (Hayajneh et al., 2020). When nurses step into the role of a transition coach, they become more engaged in the discharge process. This gives them ample opportunity to use their nursing knowledge to empower patients to take control of their health. Rational for Importance of Project 6 This project is valuable because patients who understand how to self-manage diseases have lower readmission rates (Flink & Ekstedt, 2017). Many patients do not feel prepared for their transition because they do not understand what happened during hospitalization and what to expect post-discharge, resulting in return visits that could have been avoided had they been adequately educated (Flink & Ekstedt, 2017). These readmissions result in a poor hospital reputation, decreased funding, and put a financial strain on the hospital (Upadhyay et al., 2019). This project is important as it will result in an improved discharge process. Discharge planning is often saved until the last minute and inadequately addresses the patient’s needs (Flink & Ekstedt, 2017). Discharge planning should start at admission and continue until the patient moves to the next level of care (Hayajneh et al., 2020). The planning process should include early identification and assessment of patient needs, the collaboration of multidisciplinary teams, various programs to satisfy patient requirements and preferences, and collaboration with community organizations to address gaps in their care following discharge (Hayajneh et al., 2020). Planning and education can also be improved throughout the hospital stay and the transition home by including the family or primary caregiver (Emes et al., 2019). Coordination throughout the discharge process should consist of transition coaches coordinating and communicating with patients, families, and providers throughout the discharge planning process (Hayajneh et al., 2020). This project also allows nurses to step into the role of transition coaches to support patients throughout the discharge process. Patients and their caregivers may have questions once home that they did not anticipate while at the hospital. Transition nurses communicate with patients throughout their stay and once discharged to help answer these questions and connect them to follow-up care and resources as needed (Welch et al., 2018). 7 Finally, improving discharge processes can improve profits and the quality of a hospital's reputation. Through the Affordable Care Act, readmission rates are common knowledge available to auditing agencies putting hospitals under financial stress for having high readmission rates (Upadhyay et al., 2019). With the creation of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) began reporting 30-day readmission rates for specific health conditions. (Upadhyay et al., 2019). In addition, the Hospital Readmission Reduction Program (HRRP), a Medicare value-based purchasing program, provides hospitals reporting high readmission rates with fewer funds (Upadhyay et al., 2019). The penalties for excessive readmissions have increased over time, and these benchmarks are constantly reviewed and assessed (Upadhyay et al., 2019). By improving discharge processes to better support patients before, during, and after the transition home, readmission rates can be reduced, resulting in increased profits for the hospital (Upadhyay et al., 2019). Additionally, hospital overcrowding occurs when patients are ready for discharge but waiting for the discharge process to be completed. Improving these discharge processes can act as a solution for hospital patient flow to improve employee and patient experience (Woods et al., 2020). High readmission rates can burden hospitals financially (Upadhyay et al., 2019). Patients not prepared to self-manage diseases once discharged are at risk of rehospitalization, adding to the hospital's costs (Flink & Ekstedt, 2017). By tailoring discharge education to the individual and including the caregiver throughout the process, patients are better prepared to recover successfully at home (Hayajneh et al., 2020). Using transition nurses to coordinate care among the various disciplines and community-based services can support patients through the discharge process and improve patient outcomes (Hoyer et al., 2018). Literature Review and Framework 8 This section of the paper will include a description of the literature and evidence-based practice (EBP) model used to direct this project. A literature search was conducted to identify current discharge practices, the benefits of implementing early individualized discharge plans, and the new role of transition nurses in decreasing readmissions. Implementing research into practice through EBP models to optimize outcomes is essential to healthcare (Cullen et al., 2022). The review of the literature also helped to identify an EBP model, which will be used to guide this project. The model selected is the Iowa Model Revised. A complete description of the model will be included in the next section of this paper. Framework The Iowa Model has been used for decades in research utilization for healthcare improvement. Over time, research utilization shifted to evidence-based practice (EBP) and led to the birth of the Iowa Model Revised (IMR) (Hanrahan et al., 2019). The revisions included adding a purpose statement, feedback loops, expansion of piloting, implementation, patient engagement, and sustaining change (Hanrahan et al., 2019). The IMR has been used in healthcare to make sustainable EBP changes to improve patient outcomes (Hanrahan et al., 2019). The Iowa Model Revised (IMR) framework begins by requiring the change agent to use an algorithm of steps that should be followed to implement evidence-based practice changes in healthcare. The IMR helps nurses identify the issues and opportunities for change, state the question or purpose of the proposed change, then determine if the topic is a priority. If the topic is not a priority, the model leads to the selection of a different question (Buckwalter et al., 2017). This model is a good choice for this project because improving discharge processes to decrease readmission risks significantly impacts the quality of patient outcomes. 9 The next step in the framework is creating a team and assembling, appraising, and synthesizing evidence to support this change. This team may change over time, and the team selection requires interprofessional collaboration and skill sets to plan, conduct, and evaluate the change (Buckwalter et al., 2017). Incorporating individualized discharge plans involves the collaboration of many disciplines throughout the process and is a critical component of this MSN project. After creating a team and synthesizing evidence, the IMR requires the change agent to determine if there is enough evidence to design and pilot the proposed practice change and outlines the steps needed. Part of the revision to create the IMR framework included incorporating patient and family values and preferences when designing and piloting the practice change (Buckwalter et al., 2017). Focusing on patient-centered care is a core part of the IMR and is essential for implementing this MSN project. Improving discharge processes includes the inclusion of caregivers during education sessions and preparation for discharge. Respecting patient and family values is critical to this project; therefore, the IMR supports this change process. Following the pilot of patient-centered care discharge instructions, the change is then appropriate for adoption into practice. Throughout the model, if at any point the answer to any of the questions is no, or the information is not relevant or substantial enough, it has a feedback loop that directs the change agent to backtrack to make changes as needed. This step allows you to continually improve your change process to ensure the best information is disseminated (Buckwalter et al., 2017). One of the last steps in the IMR is to integrate and sustain the practice change. This step includes monitoring key indicators through quality improvement (Buckwalter et al., 2017). In this MSN project, tracking data, specifically readmission rates, will help determine if the project 10 is successful. Fewer readmissions reported to the Center for Medicare and Medicaid Services within one month will indicate an improvement in discharge processes from the implementation of this project. Strengths and Limitations One key strength of the IMR is using bulleted suggestions throughout the steps, specifically the piloting and instituting change sections. This allows the model to be useful for various change topics (Buckwalter et al., 2017). The bulleted suggestions allow for adaptability for whatever change project is proposed. The adaptability of the framework also allows the proposed change initiatives to align with organizational priorities (Duff et al., 2020). The IMR fits with the topic of change for this project and allows for organizational priorities, such as readmission rate goals, to take precedence when implementing a new process. Another strength of this model is that it is nursing-led yet interdisciplinary (Duff et al., 2020). Part of the model includes establishing a team to address a practice issue and collaborating with multiple disciplines to find a solution (Duff et al., 2020). The Iowa Model Revised focuses on frontline issues that staff members are passionate about (Duff et al., 2020). When team members are engaged in change projects because they see the need for change in their everyday practice, positive and sustainable change is more likely. In this MSN project, the need for change in the discharge planning is primarily nurse-led with the support of other disciplines. Nurses alone cannot implement this change but require the collaboration of other healthcare team members to improve the discharge transition process. Examples of disciplines that will be important in implementing the improved transition services include pharmacists, social workers, nurses, physical and occupational therapists, and discharge planners (Ryan et al., 2019). 11 One limitation of the IMR is its need for more guidance in disseminating the information. All the other steps have specific bullet points to guide the efforts of change; however, this is lacking in the end stage of this model (Buckwalter et al., 2017). Another negative aspect of the IMR is the lack of guidance when barriers are identified. The model has options to go back and add evidence and support to the previous steps if the information is not substantial enough. However, it does not provide specific bullets to follow if there is resistance in the workplace when implementing the change (Buckwalter et al., 2017). For example, various units may have differing opinions on using individualized care plans and transition nurses when implementing the proposed change of this project, and the IMR does not have specific steps or guidance on how to mitigate such situations. Analysis of Literature A literature review was completed to gather information about current discharge processes and contributing factors to readmission rates. This search aimed to identify the gaps in current discharge processes that lead to poor patient outcomes and preventable hospital readmissions within 30 days. This search also helped to identify potential interventions that could be used to answer the posed question and to identify evidence on how to make changes. Search Strategies Several databases were used to conduct this search, including PubMed Central, National Library of Medicine, Scientific Reports, Science Direct, EBSCO, Ovid, CINAHL, and Google Scholar. The terms used in the search include current discharge processes, discharge planning, transition coaches, discharge education, care coordination, care transitions, readmission risk, and caregiver involvement. The search was limited to sources published between 2017 and 2022 to ensure that current data was used. Twenty-one sources were identified. Several Boolean 12 modifiers resulted in more focused and productive search results. Additionally, articles were excluded from the search if they were unit specific or directed toward a particular population. Three themes were identified through the search. These themes include early individualized discharge planning, caregiver involvement, and transitional care. In addition, sub-, including individual learning barriers, patient-specific education, transition coaches, interdisciplinary collaboration and community resources, and phone call follow-up, were identified. These themes are discussed in detail below. Early Individualized Discharge Planning One important finding in the literature was that discharge planning should be individualized. Patient education should prepare patients to manage their disease once discharged. A cross-sectional and descriptive study of 88 patients (Duruk et al., 2020) highlighted the need for nurses to evaluate patients' needs and readiness for education once they return home (Duruk et al., 2020). The authors found that only 31.8% of the patients in this study believed they got discharge training from healthcare professionals. In addition, even when they did receive teaching, most reported that it was insufficient for their needs (Duruk et al., 2020). Significantly, 78.4% of patients did not receive information regarding problems they may face at home, and 70% did not receive education on the effects of disease on their working life. Additionally, 48.4% did not receive instruction on medical devices and tools to be used at home, and 92% were not provided with a written source of education. The individuals who received discharge training received it on the day of discharge (Duruk et al., 2020). The literature suggests that each patient has needs specific to them and their condition, requiring an individualized plan to successfully transition home and prevent readmissions (Ryan et al., 2019). Many factors influence an individual's transition from hospital to home, such as 13 physiologic factors, physical and functional abilities, social factors, and learning abilities (Ryan et al., 2019). Additionally, the quality of the discharge education influenced patients’ self-care participation once discharged (Kang et al., 2018). Another factor affecting a “patient’s transition home included the services available to them and their family once released (Hayajneh et al., 2020). One study found that the complexity of one's discharge plan depends on their needs (Hayajneh et al., 2020). Therefore, education materials that were individualized to patients and their unique needs contributed to improved patient outcomes. Patients were also more actively involved in their education and, therefore, were more likely to take a more active role in their care (Kang et al., 2018). One study concluded that discharge planning must start on admission, and the caregiver must identify individual patient needs early to prepare a plan specific to their situation (Emes et al., 2019). Similarly, Hayajneh et al. suggested that discharge planning is a process that begins at admission and continues until the patient is moved to the next level of care (Hayajneh et al., 2020). Significantly, a systematic mixed studies review of 7 studies found that discharge processes that started on admission and continued throughout the stay led to reduced readmission and mortality rates (Kang et al., 2018). Individual Learning Barriers Along with early planning, the literature also suggested that individualized discharge plans should include identifying specific needs and learning barriers unique to the patient, such as language, learning styles, lack of previous knowledge, emotional state, etc. For example, a methodology study by Emes et al. identified the need to conduct health needs assessments as a critical component of the discharge process. One suggested intervention for addressing individual learning barriers was a health needs assessment completed through a standardized 14 checklist. This checklist was used to identify the level of support a patient may need upon discharge (Emes et al., 2019). Another finding from the literature is that readmission risk assessments should be completed early to identify patients at risk and provide personalized, targeted management (Hu et al., 2020). These risk assessments should include an examination of patients learning abilities and barriers (Hu et al., 2020). Additionally, the literature suggested that early risk screening should be done to identify patients who may require post-discharge support services and followup care with primary care doctors, post-discharge phone calls, and transitional coaches (Hoyer et al., 2018). However, Pugh et al. found that formal readmission risk assessments were not regularly performed. Identifying patients at risk for readmission or poor post-discharge outcomes is critical in implementing improved discharge processes (Welch et al., 2018). A study completed by Mitchell et al. identified the importance of anticipating patient and caregiver needs to ensure they are prepared to deliver home care and have the resources to adhere to discharge education as a crucial element of discharge planning (Mitchell et al., 2018). Additional research indicated that patients cannot always anticipate their needs for managing their conditions once home. Therefore, healthcare professionals should anticipate home-based care, supplies, transportation, medications, and medical equipment they may need once home to support a safe recovery (Mitchell et al., 2018). Patient-Specific Education In addition to addressing learning barriers, the literature suggests that discharge planning should increase the patient's understanding, motivation, and skills to self-manage diseases at home (Hayajneh et al., 2020). For example, a qualitative content analysis of 30 discharge encounters by Flink and Ekstedt discovered that discharge education did not include discussions 15 of self-management and lifestyle advice for transitioning from hospital to home (Flink & Ekstedt, 2017). Another study by Ryan et al. identified the importance of patient-specific education to facilitate self-care (Ryan et al., 2019). The authors also found that when patients' preferences are prioritized in discharge teaching, information is easier to understand, and patients are more prepared to manage their diseases at home (Kang et al., 2018). Additionally, research supports that when patients are more engaged in their self-care during discharge instructions, they are more likely to ask questions if they need clarification before discharge (Kang et al., 2018). The literature also highlighted the need for discharge planning to involve the early identification of the patient's needs (Hayajneh et al., 2020). Additionally, discharge instructions must be done through individualized interventions. The interventions outlined by Hoyer et al. included reinforcing discharge instructions, ensuring provider follow-up, recommending patient safety measures for the home, and referring patients to community resources for social needs (2018). All of these interventions were based on the specific needs of the individual. Hayajneh et al. supported this research by stating that discharge planning must include the collaboration of a multidisciplinary team and referral to programs and facilities to meet the patient's individual needs and preferences (Hayajneh et al., 2020). Along with addressing individual patient needs, discharge education needs to be individualized to the patient and explained in a way they can understand. Additionally, it must be started on admission and continued throughout the hospitalization to increase patient satisfaction after discharge (Thum et al., 2022). Quantitative correlation analysis of interventions and Health Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys evaluated the discharge processes of patients (n=957) to assess patient satisfaction and understanding of the 16 education they received upon discharge (Thum et al., 2022). The interventions in this study included a video-training program to improve nurse teaching processes, a discharge folder presented to every patient upon admission, and a list of discharge instructions to ensure all the information was met (Thum et al., 2022). Implementing these interventions improved patient satisfaction; however, the statistics did not indicate that these interventions reduced 30-day readmission rates (Thum et al., 2022). One recommended strategy to improve the effectiveness of patient education was using the teach-back method (Thum et al., 2022). The teach-back method involves the individual receiving the teaching explaining to the educator what they understood to assess comprehension (Pugh et al., 2021). Research indicated self-management is essential when educating patients before discharge (Ryan et al., 2019). The teach-back method can improve patient understanding of this information (Flink & Ekstedt, 2017). Hu et al. also highlighted the importance of using the teach back-strategy when educating patients on self-management through the recovery phase to improve patient outcomes (Hu et al., 2020). Caregiver Involvement In addition to individualized discharge planning, the literature suggests that care coordination at discharge should be patient and family-centered. This means including the patient and family in education sessions (Backman & Cho-Young, 2019). The authors state that for planning to be successful, patient families need to be involved and engaged in selfmanagement education to be prepared to help their families recover at home (Ryan et al., 2019). It also indicates that discharge planning is intended to prepare individuals and their families to independently manage their care through appropriate support and resources in their community once discharged (Hayajneh et al., 2020). 17 Similarly, research suggests that discharge planning must include family members to ensure patients and their caregivers feel prepared to manage diseases once discharged. A qualitative study by Mitchell et al. interviewed 138 patients and 110 caregivers about their discharge experiences and desired outcomes from care transition services. Three themes were identified: feeling cared for by medical providers, having accountability from the health care system, and feeling prepared and capable of implementing care plans. Interventions that supported these goals included using empathetic language, anticipating their needs to support their self-management at home, collaborative discharge planning, providing actionable information, and uninterrupted care with minimal handoffs (Mitchell et al., 2018). When these desired outcomes were met, patients and caregivers felt more prepared to adhere to discharge plans once home (Mitchell et al., 2018). In addition, this study showed how including the caregiver throughout discharge planning and interventions improved satisfaction and preparation for their role in recovering at home (Mitchell et al., 2018). The research also identified caregivers playing many roles in patient care once discharged. For example, a qualitative design study interviewed 27 patients and their caregivers within one week after being released from a hospital. The interviews were analyzed and identified the role of the caregiver significantly impacting the patient's ability to understand and adhere to discharge instructions (Hahn-Goldberg et al., 2018). This study described caregivers as having many roles, such as providing care and assistance, advocating for the patient, enacting vigilance, being a source of comfort, and acting as a translator. These roles highlighted how important it is that caregivers be involved in the discharge education and transition process to be better prepared to support the patient as they return home (Hahn-Goldberg et al., 2018). 18 Seeing that caregivers play such a significant role in care once discharged, research shows that patient and caregiver feedback on transition processes was essential when assessing interventions to improve experiences and preparation for discharge (Backman & Cho-Young, 2019). In addition, Mitchell et al. found that when caregivers were not involved in discharge planning and education, patients felt as if the hospital staff disregarded their needs and preferences (Mitchell et al., 2018). A qualitative descriptive study by Backman and Cho-Young (n=8) identified the need for effective communication between providers, patients, and their caregivers to solve this issue (Backman & Cho-Young, 2019). Additionally, it was found that many patients relied heavily on their caregivers to provide the care they needed once discharged home; therefore, caregivers needed to be included in education to improve patient outcomes and support them through follow-up appointments and recovery once released (Hahn-Goldberg et al., 2018). This is done by person and family-centered care, requiring communication and partnership between the individual, their family, and the healthcare provider. This collaboration can help achieve continuity of care and shared decisionmaking to improve the transition home and patient safety (Backman & Cho-Young, 2019). A study done by Backman and Cho-Young highlighted the inadequacy of patient and family teaching during discharge. Family members in this study reported not being aware of the potential complications of their discharged family members, leading to poor patient outcomes (Backman & Cho-Young, 2019). The authors found that effective communication between healthcare workers, family, and interdisciplinary teams was crucial for identifying and meeting each patient's needs (Emes et al., 2019). Transition Care 19 In addition to caregiver involvement, Flink & Ekstedt highlighted the importance of follow-up care, adding that several patients found it challenging to think of questions during the discharge process and often had additional questions that arose once they were home (Flink & Ekstedt, 2017). The research showed that preventing readmissions depended on an individual's ability and willingness to learn and carry out self-care activities once discharged (Hoyer et al., 2018). Additional support crucial for preventing readmissions is the quality of transitional care they receive. Transition Coaches One suggested intervention for improving transitional care is the use of transition coaches. A study by Hoyer explained the benefits of transition coaches in facilitating care and staying in contact with the patient for 30 days following discharge. These transition coaches helped facilitate follow-up care and self-care management when needed (Hoyer et al., 2018). Similarly, Welch et al. created an academic practice partnership called Health Transitions Alliance with a local university to implement health coaches who supported patients with transition care to the home setting to manage diseases once discharged (Welch et al., 2018). This program aimed to help patients transition home, improve self-management skills, and prevent readmissions (Welch et al., 2018). These health coaches implemented a plan including medication reconciliation, follow-up appointments and tests, post-discharge services, a written discharge plan, patient education, self-care educational materials, and instructions for problems they may have experienced (Welch et al., 2018). The authors found that implementing follow-up phone calls and transition nurses was associated with lower rates of 30-day readmissions (Hoyer et al., 2018; Welch et al., 2018). Interdisciplinary Collaboration and Community Resources 20 In addition to transition coaches, the literature suggests that discharge planning should be interdisciplinary, including pharmacists, social workers, nurses, physical and occupational therapists, and discharge planners (Ryan et al., 2019). For example, pugh et al. identified that one issue in the US healthcare system was the lack of coordination between inpatient and outpatient care, primary care, specialty care, home health, rehabilitation services, and social support (Pugh et al., 2021). These suboptimal transitions from hospital to home or the community source contributed to hospital readmissions (Hoyer et al., 2017). Similarly, Prusaczyk et al. identified that improving the discharge process required coordination and communication between interprofessional team members inside and outside the hospital (Prusaczyk et al., 2019). In addition, the authors found that integrated care efforts between stakeholders involved in the “patient’s care helped to ease the transition between care settings (Flink & Ekstedt, 2017). Along with interdisciplinary collaboration, the research showed that connecting individuals to community resources they may need after discharge improved the transition process for the patients. Backman and Cho-Young identified the need for improvement in the gaps in follow-up care and limited accessibility to community resources that many patients experienced (Backman & Cho-Young, 2019). The authors identified that transitioning from the hospital to home included collaboration between various settings. Additionally, early follow-up in the clinic after discharge, early assessment after hospital admission, including caregivers, and good hand-off to post-discharge providers were identified as necessary for improving patient outcomes (Ryan et al., 2019). One solution by Ryan et al. suggested making outpatient appointments before discharge to make the transition process as smooth as possible (Ryan et al., 2019). Hayajneh et al. also identified the importance of referrals to community programs to meet the patient's needs and preferences (Hayajneh et al., 2020). Finally, the authors stated that for 21 many patients, a step-down level of care is required once discharged before being able to return home, and coordinating this care before discharge was essential for improving patient outcomes (Ryan et al., 2019; Hayajneh et al., 2020; Backman & Cho-Young, 2019). A study by Hu et al. highlighted how transitional care could improve patient readiness for discharge, reduce early hospital readmissions, and improve patient satisfaction (Hu et al., 2020). This study identified critical components of transitional care planning, including patient education, discharge planning, and appointment scheduling before discharge (Hu et al., 2020). Individuals from the study who received the transitional care interventions scored higher in patient readiness for discharge in areas including critical understanding, the importance of preferences, management preparation, and a written and understandable care plan (P>0.05) (Hu et al., 2020). Additional statistics from this study found that implementing transitional care interventions improved care quality (Hu et al., 2020). One suggested intervention for decreasing readmissions is consistently implementing evidence-based care transition processes (Pugh et al., 2021). A mixed method multi-stepped observational study by Pugh et al. consisted of interviews (n=314) with staff members participating in the care transition process to assess the relationship between evidence-based transitional care processes and readmission risk. The frequency of using the 20 recommended care transition processes was scored and tested for correlation with the risk-standardized readmission rate (RSRR). The total care transition process score was correlated with RSRR (R2=0.61, p>0.007). Sites that performed all recommended transition processes had lower RSRR, indicating lower readmission rates. The two interventions performed at all facilities were pre-discharge patient education and medication reconciliation before discharge (Pugh et al., 22 2021). Other effective interventions highlighted by this study included discharge planning and post-discharge phone calls (Pugh et al., 2021). Phone Call Follow Up As mentioned above, follow-up phone calls are another proposed intervention to improve discharge processes. The literature identified that telephone follow-up supported a safe transition and improved patient experiences and outcomes (Hu et al., 2020). Similarly, a study by Ryan et al. found that individuals who did not receive discharge telephone calls had higher readmission rates than those who did (Ryan et al., 2019). A prospective randomized controlled trial of 220 patients evaluated an intervention group receiving transitional care that included a risk assessment for early readmission, education from admission to discharge, individualized discharge planning, and follow-up phone calls once a week for a month (Hu et al., 2020). Individuals in the intervention group had better discharge readiness, knowledge (P<0.001), coping ability (P<0.001), transitional care quality such as patient preferences (P<0.001), management preparation (P<0.001), and lower readmission rates (P=0.033) (Hu et al., 2020). Similarly, a study by Hoyer reported that individuals who received follow-up phone calls or support from transition coaches had a significantly lower likelihood of readmission (Hoyer et al., 2018). Another solution for follow-up communication and education suggested in the literature is telehealth and telecare for education and patient management. An article by Scalvini et al. reported a reduction in re-hospitalization rates and costs, as well as increased quality of life and patient satisfaction for those using telehealth services (Scalvini et al., 2017). Telehealth is another option for improving patient education and support through the transition process to decrease unnecessary readmissions. 23 Summary of Literature Review Findings and Application to the Project A detailed review of the current literature on discharge processes identified many gaps in transition planning that lead to unnecessary readmissions. The literature suggests that one solution to this problem is early individualized discharge planning tailored to the patient's needs and learning barriers (Ryan et al., 2019; Hayajneh et al., 2020; Emes et al., 2019). The literature also suggests that including caregivers in discharge planning and education can improve patient preparation and outcomes (Backman & Cho-Young, 2019; Ryan et al., 2019; Mitchell et al., 2018). Additionally, interventions identified in the literature to improve patient preparation include transition coaches, phone call follow-up, and multidisciplinary teams to help patients access the resources and community support needed once discharged (Hoyer et al., 2017; Welch et al., 2018; Pugh et al., 2021; Hu et al., 2020). This information has helped identify interventions to support the project's potential for decreasing readmission rates through improved discharge processes. Because the literature demonstrated the importance of early risk screenings and individualized discharge planning, this project will implement discharge planning sessions tailored to the “patient’s specific needs and include the caregiver throughout these meetings. This project will also use the information on transitional care to guide the implementation of transition coaches to collaborate with interdisciplinary and community resources to support patients during and after discharge. Project Methodology This project will prepare registered nurses (RNs ) to support patients through the transition from hospital to home to improve patient outcomes and decrease readmission rates. This outcome will be achieved through education sessions tailored to the individual needs of 24 each patient and transition coaches to support the patient through this process and after discharge through follow-up phone calls. Four deliverables have been created to promote the implementation of this project. The deliverables include (a) a risk needs assessment for patients upon admission, (b) an educational PowerPoint for the transition coaches, (c) a knowledge assessment of PowerPoint materials, (d) a patient and caregiver handout for follow-up phone call information, and (e) an algorithm for the need of follow-up phone calls. Description and Development of Project Deliverables Five items were created to aid in the implementation of this project. In this section, the deliverables will be described in detail, including the purpose of each and its benefit to this project. Readmission Risk Health Needs Assessment The first item is a standardized readmission risk health needs assessment (RRHNA) (see Appendix A). The RRHNA includes questions from current literature (Hayajneh et al., 2020; Emes et al., 2019; Hu et al., 2020) that identify patient-specific education needs and whether the patient would benefit from a transition coach or follow-up phone call. This assessment aims to record information needed to understand the level of support the patient will require upon discharge from the hospital. The deliverable will be added to the current admission paperwork. Educational PowerPoint for Nurses as Transition Coaches The next deliverable is an educational PowerPoint for caregivers (see Appendix B). The PowerPoint includes information gathered from current literature on the health needs assessments and follow-up phone calls (Hayajneh et al., 2020; Hoyer et al., 2017). Nurses stepping into the role of a transition coach will view the PowerPoint for initial training and use it 25 as a reference during practice. The education from this deliverable will provide nurses with a better understanding of the transition coach role. The PowerPoint also includes instructions on promoting follow-up with primary or specialty care and patient education using the teach-back method (Hoyer et al., 2017). Knowledge Assessment of PowerPoint Materials This assessment is for RNs who have reviewed the educational PowerPoint on nurses as transition coaches (see Appendix C). It allows managers to assess their staff's knowledge of their role in the proposed changes. It is also a chance for RNs to test what they have learned and identify areas they need to review or questions they have about this role. This document includes a question assessing the confidence of staff in their new role. It encourages staff members to contact their unit manager or educator with additional questions. Assessing the staff's knowledge as transition coaches can identify gaps in current education and training to guide future implementation. Patient Phone-Call Follow-Up Handout The third deliverable is an educational pamphlet for patients and their caregivers (see Appendix D). This handout will be given to patients who qualify for and may benefit from phone-call follow-ups according to the transitional care table (see Appendix E). The purpose of this handout is to educate patients and their caregivers on what to expect from their follow-up phone call and its purpose. Phone call follow-ups are completed to review discharge instructions, identify potential problems, and connect patients to resources as needed for any issues they have (Hoyer et al., 2017; Ryan et al., 2019; Hu et al., 2020). Transitional Care Table 26 The final deliverable created for this project is a table to determine patient eligibility who may benefit from a transition coach or follow-up phone call (see Appendix E). The RRHNA will be used to determine the needs of each patient according to this table. Patients discharged to a skilled nursing facility/rehabilitation building or with home health services are not eligible for transitional services (Hoyer et al., 2017). Based on the readmission risk score from the RRHNA, this table aims to determine which patients need a transition coach through the discharge process and which patients would benefit from a follow-up phone call (Hoyer et al., 2017; Welch et al., 2018). Plan and Implementation Process Once this project is approved, it will be implemented on the medical/surgical unit for the year's first quarter. Management will meet with unit leaders to discuss the change and provide an opportunity to promote the support of the staffing team on this project. Specific individuals will be needed to implement this project and may change depending on skill sets and needs (Buckwalter et al., 2017). Examples of team members may include physicians, nursing administration, unit managers, floor staff, social workers, and physical and occupational therapists. During this meeting, the presentation and explanation of the project and deliverables will be emphasized to gain support from the RN leadership. The presentation will include the rationale for the deliverables (see Appendix) and the positive impact this project can have on patient care, education, and post-discharge outcomes. The intended outcomes of this project advocate for education and transitional services specific to each patient’s needs, emphasizing the importance of patient-centered care. As both the IMR and this project have identified patientcentered care as a priority, there is alignment with the chosen framework and the goals of these changes. 27 This project's success will be measured by examining readmission rates following the first quarter of implementation. If the implementation of this project appears to improve unnecessary readmission rates, it will be implemented on subsequent floors throughout the hospital. If, at any point during implementation, more data or revisions are needed, the IMR framework can help to guide us to continually improve the change process by looping back to previous steps (Buckwalter et al., 2017). For example, the need for changes and adjustments will be assessed after piloting this project on the medical/surgical unit. After these adjustments are made, the process will be repeated on the same unit for the following quarter. Finally, the project will be implemented on additional floors in the next quarter if no other changes are needed. Interdisciplinary Teamwork Discharge planning should include integrated efforts between multiple disciplines to ease the transition from hospital to home (Flink & Ekstedt, 2017). A lack of coordination between various levels of care and disciplines can lead to suboptimal patient transitions (Pugh et al., 2021). Proper interdisciplinary collaboration will decrease readmission rates, and patient outcomes can improve. Several key team members will help to implement this important change. Below, each team member has been described in detail. Transition Coach. The transition coaches for this project will be registered nurses. RNs will be educated on how to act as transition coaches and all that entails. In addition, they will perform follow-up phone calls when needed and aid patients in their transition from hospital to home. This role is essential in answering patient questions and concerns after discharge and supporting safe transitions home, enhanced patient experience, and improved outcomes (Hu et al., 2020). 28 Social Services. Social services will be necessary for the implementation of this project. Social workers will collaborate with the transition coaches to aid in screening, psychosocial assessments, and providing community service referrals. In addition, social work is essential in connecting patients to the resources available around them once discharged. Social workers can coordinate and communicate with community resources to make the transition from hospital to home smoother for patients; this change can improve patient satisfaction and outcomes (Backman & Cho-Young; Hayajneh et al., 2020; Ryan et al., 2019). Physical Therapy (PT) and Occupational Therapy (OT). Physical and occupational therapy personnel will collaborate on this project to help identify any rehabilitation needs patients may need once discharged. In addition, they will communicate and collaborate with the RNs throughout the patient’s stay to prepare for the patient's physical needs once home. This collaboration will include identifying ways to aid in daily living and working once discharged as needed. Patients are not always aware of their limitations once home; therefore, PT and OT play an essential role in identifying what support may be required depending on their needs (Emes et al., 2019). This information must be communicated to the RNs and nurse leadership to properly prepare the patient for discharge and prevent any adverse events from occurring once the patient returns home. Nursing Leadership. Nursing leadership, which includes unit managers, charge nurses, and nurse educators, will be critical in this project in preparing staff to implement the deliverables and support the team throughout the involved changes. Unit managers must be ready to help the staff members in their unit throughout this project. The leaders must also be prepared to answer questions others might have about the process. 29 Charge nurses must be prepared to aid in carrying out the changes and support the nurses in collaborating with the interdisciplinary teams involved in discharge planning and education. Nurse educators will be responsible for helping spread the information through email and a PowerPoint for weekly huddles. The educators will also provide additional help throughout the project implementation as needed. Implementing these changes throughout the unit will be a team collaboration and require quality communication and teamwork to ensure patients receive the best care possible to support them through discharge to prevent unnecessary readmissions. Timeline The implementation of this project requires the coordination and collaboration of the floor nurses, unit educators, social services, and physical and occupational therapists. It will begin the month before the start of the new quarter. First, a meeting with the unit manager, educator, and leadership team must be held to introduce the project and deliverables. All meetings will be conducted via Microsoft Teams and recorded for future reference or for those unable to attend. Next, a meeting with the charge nurses and unit educators will prepare the charge nurses to use the transitional care table to determine specific patient needs for discharge. Next, a meeting will be held to present the unit staff with the Nurses as Transition Coaches PowerPoint, the phone call follow-up patient educational pamphlet, and the RRHNA. Additionally, the information will be included in the weekly huddle and distributed through email to unit staff. Finally, the week before the start of the first quarter, staff will review the information and have a final meeting via Teams to discuss questions and concerns about implementation. Barring any complications or concerns, the changes will be implemented and monitored on the unit. After one quarter, readmission numbers will be reassessed, and any improvements 30 needed will be discussed and reviewed. This process will be repeated on the same unit for the next quarter if changes are required. Based on the results, if successful, this project will be implemented on additional units in the hospital and continuously evaluated and assessed for needed improvements. This timeline suggests an allotment spanning approximately four months to plan, implement, and evaluate this project (Appendix F). Plan for Evaluation of Project The success of this project will be determined by comparing the readmission numbers from the unit before implementation and compared to the numbers after. A 1% decrease in readmissions at the end of the quarter will indicate success for the first unit the project is trialed on. After the first quarter, this numerical goal will be assessed to determine if it needs revision. Team members will be asked to offer suggestions on improving this program's education and implementation. Recommendations from individuals implementing the change will be considered before implementing it on additional floors. Any modifications or revisions will be discussed and evaluated before expanding the project. Charge nurses will be responsible for following up on implementing the new process for every discharge they have on their shift through verbal confirmation with the discharging nurse. The charge nurse will also review the documentation for each discharge, including the RRHNA and documentation of which transitional care tool was used. This information will be recorded on paper and monitored by unit managers throughout the quarter. In addition, nurses who are consistently not using the new process will have a meeting with the unit manager for reeducation on the changes and to identify the barriers stopping this nurse from implementing the new procedures. 31 The evaluation of patient satisfaction is an essential component of this project. It will be done through a survey sent via email to the patients who received the transitional care services. This survey will assess the patient’s satisfaction with the education and support they received in the hospital and their assigned transitional care support. The questions on the survey will have patients rank their satisfaction scores on a scale of one to five, with one being very dissatisfied and five being highly satisfied. A mean satisfaction score of four is the goal for this project. The survey will also provide an area for comments on opinions, what they liked about the services, and what they disliked. There will also be an option to receive a follow-up call from the administrative team to further discuss their thoughts on the new process. Ethical Considerations There are multiple ethical considerations to address in the implementation of this project. First, this project reflects social responsibility through its goal to prevent unnecessary readmissions. Improving discharge processes can reduce the likelihood of hospital readmission, saving patients stress and hospital bills. Staff members may choose to refrain from participating in this project. These staff members should be provided with the project information and how their participation can improve patient outcomes and prevent readmissions to encourage them to participate. They should also be given the PowerPoint information on acting as transition coaches and conducting follow-up phone calls before deciding not to participate. This project supports non-discriminative behaviors by offering the same resources to all qualifying individuals. All patients needing additional support determined through the transitional care table will have these services presented to them. Individuals who refuse the project deliverables, specifically the follow-up phone call and transition nurse, can refuse these services. Some patients who do not receive the option for transitional services may be upset that 32 they were not given that option. To deal with these frustrations, the criteria will be explained. After the first quarter of implementation, the criteria determining who receives these services may need to be broadened to decrease the admission rates further. Discussion Unnecessary readmissions occur every day due to a lack of proper education and support through the discharge process. This project suggests using nurses as transition coaches and a phone call follow-up to support patients better as they transition home to reduce preventable readmissions. Additionally, this project promotes patient-specific education, caregiver inclusion, and early planning to provide a smooth transition from the hospital to their next level of care. These interventions can also aid patients in preparing to self-manage diseases once home (Hoyer et al., 2018; Welch et al., 2018). This section will discuss the dissemination, strengths and weaknesses, and future research recommendations Evidence-Based Solutions for Dissemination After a successful pilot on the first unit, the project will be implemented hospital-wide. The first unit will have a meeting to discuss the project and an opportunity to provide feedback. An additional survey link will be provided for anonymous comments and suggestions. The faculty feedback, patient satisfaction scores, and readmission rates will be shared with the nurse administrator and other hospital leadership before being implemented on other units. The remaining units' implementations will be similar, and will include meetings to discuss staff feedback and suggestions for improvement. A final report will be shared via email with the board members and corporate stakeholders. This information will be used to determine if this program will be implemented at other facilities throughout the company. Further dissemination of the final report will be shared 33 via email to other facilities in the organization to spread awareness of changes being made and their impact on readmission rates. Additionally, this program will be shared with WSU faculty and peers through a presentation. Significance to Advance Nursing Practice This project can benefit the nursing profession as it helps provide continuity of care and support throughout the patient’s transition through various health settings. This support starts with early identification of needs through the RRHNA on admission and with follow-up support after the patient leaves the hospital. Instead of interrupting the pathway of care by ending services once the patient leaves the facility, nurses can support self-management by providing support once patients go home. Additionally, this project benefits the nursing profession by decreasing unnecessary readmissions. By doing so, the hospital will benefit financially from reimbursement from Medicare and Medicaid versus the penalties they face for preventable readmissions (Upadhyay et al., 2019). This project also benefits patients for similar reasons. In addition, this project can save patients unnecessary medical costs by decreasing hospital readmissions. Not only does this benefit patients financially, but it also increases patient satisfaction and the likelihood that they will recommend and return to the facility for future health needs. It also reduces patients’ stress as they try to manage their conditions at home. Additionally, this change can benefit the caregivers of the patients by preventing some of the stress that caregivers may experience caring for their family members once they get home (Mitchell et al., 2018). Implications This project will prepare nurses to support patients transitioning from hospital to home by providing nurses with guidance in their new role as transition coaches. Additionally, it provides 34 multiple tools for nurses to use as a reference for implementing the transitional care services. Implementing these changes will increase support for discharging patients and improve patient satisfaction and outcomes by preventing unnecessary readmissions. The RNs who function in transition coach roles may also experience greater job satisfaction by following and supporting their patients through their transition home. One limitation of this project is the possibility of a lack of cooperation or improper implementation. Although the goal is to educate staff members to understand and support the reasoning for this project, compliance and consistency are possible obstacles to sustainable changes. One way to reduce this obstacle is to have the charge nurse aid in implementing new discharge processes until the nurse feels comfortable doing it independently or assign an experienced nurse on shift to help them. Another potential problem for this project is the limitations of the RRHNA. Although much effort was put into accounting for significant contributing factors potentially affecting readmission risk, some patients may fall through the gaps. To address this, any nurse concerned about their patient or worries they may be at risk for readmission can discuss it with their charge nurse. The charge nurse can help ensure the patient receives the follow-up services as they see fit. Other methods to reduce possible obstacles include providing frequent reminders and incentives to the nurses to implement the new changes consistently. Posting visual reminders in patient rooms and at the nurse's station can also help guide nurses through the process as needed. Charge nurses can also encourage their staff to revisit educational materials as needed or provide additional information and resources in huddles and unit emails. 35 This project supports nursing knowledge by allowing nurses to step into a more patientcentered role by supporting them both in the hospital and after returning home. The nursing profession aims to treat the whole person and help the patient develop self-management skills to improve their daily activities, positively impacting their overall well-being. This change provides nurses with more opportunities to educate patients and find joy and satisfaction in implementing their nursing knowledge in a way that impacts their patients' lives. Recommendations The topic of readmission risk assessments has been mentioned in more than one study; however, one specific tool or set of questions and criteria has yet to be identified. Further, few studies clearly outline the specifics of the transition coach role. Therefore, additional research should be conducted to determine the best tools available for assessing and predicting readmission risks and to establish the specific criteria for the scope of practice for nurses as transition coaches. Conclusion Identifying ways to prevent readmissions is no simple task, but when done correctly, it can significantly impact organizational success, reimbursement, and, more importantly, patient satisfaction and outcomes (Upadhyay et al., 2019). For example, patients who receive a phone call follow-up or the support of a transition coach through their discharge are less likely to have an unexpected readmission (Hoyer et al., 2018). Additionally, early, individualized discharge planning and patient-specific education can improve patient preparedness to self-manage diseases at home and improve their overall health outcomes (Kang et al., 2018; Hayajneh et al., 2020). 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Readmission rates and Their Impact on Hospital Financial Performance: A Study of Washington Hospitals. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 56, 004695801986038. https://doi.org/10.1177/0046958019860386 Woods, R., Sandoval, R., Vermillion, G., Bates-Jackson, B., Nwankwo, A., Canamar, C. P., & Sarff, L. (2020). The Discharge Lounge. Journal of Nursing Care Quality, 35(3), 240–244. https://doi.org/10.1097/ncq.0000000000000469 41 Appendix A Readmission Risk Health Needs Assessment 42 Appendix B Educational PowerPoint for Nurses as Transition Coaches 43 44 45 46 47 Appendix C Knowledge Assessment of PowerPoint Materials 48 49 Appendix D Patient Phone-Call Follow-Up Handout 50 Appendix E Transitional Care Table 51 Appendix F Timeline Project Implementation Week 1 Week 2 Teams meeting with unit managers, educators, and leadership team to introduce project and deliverables. Teams meeting with Charge Nurses and Unit Educators on how to use the Transitional Care Table to determine specific needs for discharge. Teams meeting to present unit staff with the nurse as transition coach PowerPoint, phone-call follow-up patient handout, and RRHNA. Week 3 Deliverables will be included in the weekly Huddle and distributed through email for reference. Week 4 Final Teams meeting to discuss questions and concerns before implementation. Quarter 1 Implementation and monitoring of project changes. End of Quarter 1 Evaluation of readmission rates before and after project implementation will be assessed to determine effectiveness. If changes are needed, they will be reviewed, revised, and the process will be repeated for the same unit. Ongoing If adjustments are needed, they will be changed on the unit the following quarter and assessed again for success. If results show success, the project will be implemented on other units in a similar fashion. The project will be continuously assessed and improved if needed.