Evidence-Based Practice Change Process

My actual job Title is RN/Case management for Insurance company, one of my job responsibilities is to reduce hospitalization admissions. Please follow direction below. I uploaded the Form to be used (Required) and paste below the systemic review. Please follow star point direction. American sources is instructed to be used. Thanks again

Work through each step of the ACE Star Model as outlined on the assignment form (Star Points 1-5: Discovery, Summary, Translation, Implementation, and Evaluation). Respond to the instructions provided on the form.

Selected Systematic Review
A systematic review from the CCN Library databases was selected, identified, and was appropriate for the selected nursing change process.
Star Point 1 (Discovery)

*******Selected Systemic Review Below********

Record: 1
Title:
Case Management: Readmissions
Authors:
Mennella H, DNP, ANCC-BC; Key M, ANP-C, APRN, AOCNP, CCRN
Affiliation:
Cinahl Information Systems, Glendale, CA
Editors:
Pravikoff D, RN, PhD, FAAN
Source:
CINAHL Nursing Guide EBSCO Publishing, (Ipswich, Massachusetts), 2018 Jun 08.
Publication Type:
Evidence-Based Care Sheet
Language:
English
Major Subjects:
Case Management
Readmission
Minor Subjects:
Nursing Assessment
Entry Date:
20121123
Revision Date:
06/08/2018
Accession Number:
T708339
Persistent link to this record (Permalink):
https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=T708339&site=eds-live&scope=site
Cut and Paste:
Case Management: Readmissions
Database:
Nursing Reference Center Plus

Evidence-Based Care Sheet
Case Management: Readmissions
By: Hillary Mennella, DNP, ANCC-BC
Cinahl Information Systems, Glendale, CA
Monica Key, ANP-C, APRN, AOCNP, CCRN
Cinahl Information Systems, Glendale, CA
Edited by: Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
What We Know
Readmission is defined as patient admission to the same or a different hospital within a period of 30 days of discharge(1,3,4)
The estimated national 30-day, all-cause, hospital readmission rate for Medicare beneficiaries in the United States was 18.4% in 2012, down from an average of 19% during the period 2007–2011; this translates to ~ 70,000 fewer readmissions in 2012 than would have occurred if the readmission rate had remained at 19%(7)
An estimated two-thirds of readmissions are preventable(1)
Reasons for readmission include premature discharge, inappropriate treatment, and inadequate patient education and discharge planning(1)
Hospitals serving a higher population of patients from a lower socioeconomic status often have higher rates than the national average for readmission,resulting in lower Medicare reimbursements. Patients from a lower socioeconomic status can have difficulty procuring follow-up appointments, food, and medications after discharge(10)
Even though readmission rates have decreased, one in five Medicare patients are still being readmitted within a month(6)
In 2010 the Affordable Care Act (ACA) established the Hospital Readmissions Reduction Program, which provides financial incentives to hospitals to reduce readmissions(3,4)
The program requires a reduction in Medicare and Medicaid reimbursement to applicable hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), and elective hip and/or total knee replacement. A readmission measure for coronary artery bypass graft (CABG) surgery was added in 2016(3,4)
Readmission reimbursement calculations for individual hospitals are based on national readmission rates for these specific diagnoses and are intended to improve health care for beneficiaries and control unnecessary spending of healthcare dollars(6)
As of October 1, 2016, penalties went into effect and are applied to all Medicare discharges, with an average penalty that is less than 1% of the Medicare payment(6)
By the end of 2016 hospitals lost a total of $420 million in penalties for excess readmissions(6)
Hospitals can lose up to 3% of their Medicare reimbursement if they have higher than average 30-day readmissions for patients with heart failure, heart attack, elective hip or knee replacement, pneumonia, and an acute exacerbation of COPD(6)
Current penalties are not large enough to have a big impact on the bottom line and for some hospitals the penalties are not high enough to justify the cost of adding staff or taking other steps to reduce readmissions(6)
Beginning in 2017 the hospital’s base operating pay could be reduced by 6% from Medicare if a hospital receives the maximum penalties(6)
Authors of a large study in New York, which utilized data from de-identified Medicaid claims discovered that high-value post-discharge utilization resulted in fewer inpatient re-hospitalizations. This required population-based transitional care strategies to improve continuity between settings and considers the illness complexity of the patient(8)
Case managers can be utilized to make the difference on the bottom line for hospitals by putting in place processes to reduce readmissions(6)
A multi-layered approach is necessary to make a positive impact and reduce hospital readmissions. Some hospitals have a group of nurses acting as health coaches for hundreds of at-risk patients. In some cases these nurses will visit the patients in their home and routinely follow up with them(6)
This multi-layered approach along the entire continuum has been shown to positively impact readmission rates(6)
A readmission task force can help to analyze hospital data and determine the key diagnoses for the focus of the clinical team to prevent readmissions(6)
Case managers play an important role in the patient discharge process and in the prevention of unnecessary readmissions. Discharge is a shared responsibility between staff members, the patient, caregivers, and the case manager; the case manager is responsible for the safe and smooth transition of care. Collaboration between the case manager, social worker, and treating clinician must lead to change at the practice level to decrease readmission rates
Case managers will require extensive education for the advanced practice role and to perform the readmission screening surveys that are anticipated to emerge during healthcare reform
In Tampa, Florida the Veterans Administration Health Center used telehealth and phone care initiatives to reduce congestive heart failure hospital readmission rates by 5%, while also providing a decrease in costs, and improved veteran satisfaction with overall care experience(12)
Similarly, in 2013, case management leadership in Flagstaff, Arizona used the Better Outcomes for Older Adults through Safe Transitions (BOOST; a tool used for evidence-based quality improvement in the hospital setting) program to implement telehealth and follow-up phone calls,effectively reducing all-cause 30-day readmissions; the readmission rate decreased from 23% to 12%. In 2014. The program was implemented in another Flagstaff system hospital to include pneumonia, COPD, total joint replacements, and AMI, demonstrating an all-cause Medicare 30-day readmission rate of 10.8% compared to the national average of over 18%. and scheduled post-acute follow-up services within one day of patient discharge(2)
Researchers in a randomized controlled study of 281 older adults with at least two medical diagnoses demonstrated that a nurse-led CM program involving basic care, treatment compliance, and arrangements for outpatient follow-up appointments significantly reduced hospital readmission rates
New York State has one of the highest readmission rates in the U.S. A New York hospital decreased 30-day readmissions by 70% for their highest-risk patients by implementing a care coordination team of case managers, social workers, and patient service coordinators. The team was trained by the BOOST program and also visited readmitted patients to find out why readmission was necessary
Pima Council on Aging and Carondelet Health Network have partnered to provide follow-up care coordination for at-risk patients being discharged from the hospital. The U.S. Centers for Medicare & Medicaid Services (CMS) has referred to the program as a National Best Practice in reducing hospital readmission rates(11)
What We Can Do
Case managers and hospitals need to look beyond the hospital walls and determine what happens to patients throughout the continuum to better avoid readmissions(9)
Become knowledgeable about CM as an approach to reduce patient readmissions so you can accurately assess your patients’ personal characteristics and health education needs; share this information with your colleagues
Improving communication with post-acute providers is a critical part of reducing readmissions. Sending a written report as well as talking to a clinician at a skilled nursing facility, home health agency, or long-term acute care hospital is one way to improve communication(9)
Case managers should spend time with the patients and family members for an understanding of patient characteristics, such as culture, language barriers, socioeconomic status, healthcare literacy, and access to social support, and take these dynamics into consideration when developing a discharge plan(9)
If a patient does not have immediate family or other support, then looking for other resources, such as community agencies, churches, and neighbors becomes vital. Being creative is important for case managers to connect patients with resources before discharge(9)
Refer appropriate patients to palliative care is a critical part of reducing readmissions; this involves educating patients and family members on palliative care and end-of-life issues(5)
Work closely with case managers who are embedded in physician offices and other venues of care. They are a great source of information for developing a successful discharge plan because they know what services can safely be provided in which venue of care. One example is residents of supportive living centers might be able to receive home care services and avoid a skilled nursing facility admission(5)
Facilitate discharges early in the day, considering elderly patients have trouble driving at night and many pharmacies are closed at night(5)
Follow up with assisted living residents to ensure communication with a clinician to provide the details of the hospitalization and the treatment plan(5)
Collaborate with others in your healthcare facility to initiate a CM program to meet the needs of every patient and to maintain compliance with healthcare reform quality outcome readmission measures
Track and trend readmission rates and analyze core reasons for rehospitalization
Involve patients and their caregivers in the discharge planning process, provide education, and implement the teach-back method regarding performing patient care after discharge to home
Collaborate with others in your healthcare facility to identify and implement validated and reliable screening tools for increased risk for readmission among your patient population
Participate in continuing education for implementation of readmission screening surveys
References
1. Adeoye, S., & Pineo, T. (2014). Reducing excess readmission 101: Evidence-driven strategies and facility-specific initiatives. Journal of Medical Practice Management, 30(1), 42-48. (RV)
2. Care management revamp helps keep readmission rates low. (2017). Hospital Case Management, 25(3), 39-41. (GI)
3. Centers for Medicare & Medicaid Services. (n.d.). The Hospital Readmissions Reduction Program (HRRP). Retrieved May 29, 2018, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program.html (GI)
4. Department of Health and Human Services. (2012). 42 CRF Parts 412, 413, 424, et al. Medicare Program; Hospital inpatient prospective payment systems for acute care hospitals and the long-term are hospital prospective payment system and fiscal year 2013 rates; hospitals’ resident caps for graduate medical education payment purposes; quality reporting requirements for specific providers and for ambulatory surgical centers, 77(170), 53258-53750. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2012-08-31/pdf/2012-19079.pdf (L)
5. Five more ways to improve readmissions, according to the experts. (2015). Hospital Case Management, 23(1), 4-5. (QI)
6. Five years later, hospitals still struggle with readmissions. (2015). Hospital Case Management: The Monthly Update on Hospital-Based Care Planning and Critical Paths, 23(11), 141-144. (PP)
7. Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., & Brennan, N. (2013). Medicare readmission rates showed meaningful decline in 2012. Medicare & Medicaid Research Review, 3(2), E1-E12. doi:10.5600/mmrr.003.02.b01 (PGR)
8. Hewner, S., Casucci, S., & Castner, J. (2016). The roles of chronic disease complexity, health system integration, and care management in post-discharge healthcare utilization in a low-income population. Research in Nursing & Health, 39(4), 215-228. doi:10.1002/nur.21731 (GI)
9. Hospitals are still struggling with reducing readmissions. (2015). Hospital Case Management, 23(1), 1-4. (PP)
10. Hospitals can now factor socioeconomic status into readmissions. (2017). Hospital Case Management, 25(3), 41-42. (GI)
11. Hospitals, Council on Aging Partner to reduce readmissions. (2015). Hospital Case Management, 23(1), 9-10. (PP)
12. Messina, W. (2016). Decreasing congestive heart failure readmission rates within 30 days at the Tampa VA. Nursing Administration Quarterly, 40(2), 146-152. doi:10.1097/NAQ.0000000000000154 (QI)
Reviewer(s)
Debra Balderrama, RN, MSCIS, Clinical Informatics Services, Tujunga, CA
Alysia Gilreath-Osoff, RN, BSN, CEN, SANE, Cinahl Information Systems, Glendale, CA
Nursing Executive Practice Council, Glendale Adventist Medical Center, Glendale, CA
Original document: 2012 Nov 23
Latest revision: 2018 Jun 08
Coding Matrix
References are rated using the following codes,
listed in order of strength:
Code
Description
M
Published meta-analysis
SR
Published systematic or integrative literature review
RCT
Published research (randomized controlled trial)
R
Published research (not randomized controlled trial)
C
Case histories, case studies
G
Published guidelines
RV
Published review of the literature
RU
Published research utilization report
QI
Published quality improvement report
L
Legislation
PGR
Published government report
PFR
Published funded report
PP
Policies, procedures, protocols
X
Practice exemplars, stories, opinions
GI
General or background information/texts/reports
U
Unpublished research, reviews, poster presentations or other such materials
CP
Conference proceedings, abstracts, presentation

****Star Point Direction Continues******
The topic, nursing practice issue, rationale and scope of the problem were clearly identified and described.
Star Point 2 (Summary)
The NURSING practice problem, NURSING related PICOT question, a systematic review from any database in the Chamberlain Library, and other optional references, evidence summary, strength, and solutions, are listed and described.
Star Point 3 (Translation)
Care standards, practice guidelines, or protocols; stakeholders and their roles and responsibilities; the nursing role; rationale for including certain stakeholders, and cost analysis plan are addressed.
This criterion is linked to a Learning Outcome
Star Point 4 (Implementation)
Permission process, education plan, timeline, measurable outcomes, forms, resources, and stakeholder meetings, are addressed.
Star Point 5 (Evaluation)
Reporting results, process and next steps are addressed.
Presentation
Information was presented clearly and thoughts were well organized and logical.
This criterion is linked to a Learning Outcome
Mechanics/APA
The systematic review and any other scholarly resources were properly listed in APA format.
The writing includes error free grammar and spelling, and complete sentence structure.