Reducing children require caregivers to engage and

Reducing Readmissions in Pediatric
Patients with Chronic Respiratory Illnesses

readmissions are costly to the health care system and lead to poor patient
outcomes.  In 2004, unplanned all-cause
readmissions cost Medicare $17.4 billion dollars. (Amin et al., 2014) In response to
the Affordable Care Act, The Centers for Medicare and Medicaid Services
proposed a change in reimbursement penalties for hospitals beginning Oct 1,
2012. (Amin et al., p. 255) Due
to these readmission penalties hospital has been trying to reduce < 30-day unplanned readmissions.  The purpose of this proposal is to reduce readmissions in pediatric patients with chronic respiratory conditions using case managers to follow patient from admission, during hospital stay, upon discharge, and post discharge management.  Change Model Overview "The Ace Star Model of Knowledge Transformation is a model for understanding cycles, nature, and characteristics of knowledge that are utilized in various aspects of evidence-based practice (EBP)." (Stevens, n.d., p. 1) This model organizes old and new concepts of care into a whole and provides a framework to organize EBP processes and approaches.  (Stevens, p. 1) Nurses should use this model because it is a simple framework for systematically putting EBP processes into operation.  (Stevens) Define the Scope of the EBP Penalties for hospital readmission for the 2017 fiscal year were 537 million.  They are projected to reach 564 million for the 2018 fiscal year. (Maguire, 2017, p. 1) Around three-fourths of eligible hospitals will be hit with some level of penalty for readmissions.  (Maguire, p. 1) "A readmission rate of up to 18-20% means that up to one of five patients are expected to come back to the hospital." (Hunter, Nelson, & Birmingham, 2013, p. 56) The practice issue focused on in this proposal is frequent hospital readmissions in pediatric patients with chronic respiratory conditions.  Children with chronic respiratory conditions are discharged on self-management discharge plans.  Caregivers are given discharge plans at the time of discharge.  Most times given packets about diseases to read.  There is no follow-up post hospitalization.  Caregivers are told to schedule follow up appointments.  Managing chronic respiratory illnesses in children require caregivers to engage and be proactive in the health care plan and this may be difficult for parents of chronically ill children.  Caregivers are often uneducated on chronic respiratory illnesses or do not understand the limited educational information they are given.  There may be cultural differences that may interfere in the health care plan.  Care coordination between the primary care physician, the interdisciplinary team, and caregivers needs to be at admission.  Most times it begins when the primary care physician puts in a discharge order and it becomes rushed.  The discharge plan needs to include the primary caregivers.  The caregivers must fully understand the discharge instructions /health care plan and be able to execute it.  Care coordinators must be aware of any barriers that would prevent the caregivers from executing the health care plan.  The goal of the plan should be to improve their support network, the emotional well-being of the patient and caregivers, and improve the quality of life for the patient.  Stakeholders ·         Team Leader ·         Case Managers x4 ·         Administrative Assistant Determine Responsibility of Team Members The team leader will oversee the entire project.  The team leader will educate ER physicians, hospitalists, and primary care pediatricians so they are aware of the program and will actively engage.  The team leader will coordinate with other interdisciplinary programs and companies to educate them about the program and educate them about the case manager who will be calling and setting up appointments for services.  The team leader will report findings to hospital administration via quarterly reports and readmission committee meetings.  The team leader will also collect all data regarding the program to determine if the program is successful.  The case managers will contact patient and care giver upon admission or while the patient is in the emergency room.  The case managers will develop a trusting relationship with the patient and care giver.  The case manager will be available to answer all questions and fully educate the caregivers during the hospital stay.  The case manager will do a care coordination evaluation upon first contact with patient and caregivers to identify needs and barriers that may affect the patient upon discharge.  The care manager will make follow up appointments within a 7-day window post discharge.  The care manager will arrange transportation to and from follow up appointments as needed.  The case manager will set up home health or any other therapies needed.  The case manager will order and ensure delivery of any medical equipment needed at home.  The case manager will provide education about the patient's chronic illness and acute illness.  The case manager will ensure that the caregiver was able to fully understand materials given and answer any questions.  The case manager will conduct home visits and provide any additional education (i.e. smoking cessation).  The case manager will be phone for any questions or issues the care giver may have.  The administrative assistant will coordinate all schedules for care mangers.  Will answer phone calls.  Will assign all referrals to care managers.  Will assist in collecting data from the program and keeping of a record of all admissions and discharges of patients with chronic respiratory diseases.  Evidence The following evidence was gathered literature, financial analysis, expert opinion, and patient preferences.  The literature search assisted in finding all relevant literature regarding chronic respiratory illnesses and discharge planning.  All relevant literature on educating caregivers, staff and physicians.  All relevant literature regarding preventing readmission through discharge planning and care coordination.  Obtained expert opinion from pulmonologists, pediatricians, pulmonary function technicians, and respiratory therapists.  Obtained information on managing these chronic illnesses and educating the family members.  Researched and allowed for acknowledging patient/family preferences in the care coordination evaluation.  Will be aware and respectful of patient/caregiver preferences for compliance with discharge plan/health care plan.  A financial analysis was performed to be aware of how much this program will cost and to remain cost effective.  It is also important to keep track of how much money preventing hospital readmission will save the hospital or health care system to report to administration for the success of the program.  Also researched how much readmission cost the hospital/health care system to compare the two.  Summarize the Evidence The case management program may reduce hospital readmission of pediatric patients with chronic respiratory conditions by: 1.      Improving communication between providers and patients/caregivers leading to better self-management plans. 2.      Understanding the types of available inpatient and outpatient hospital services to maximize outpatient care. 3.      Coordinating care from hospital to home.  4.      Improved health education and promotion. 5.      Introduction to holistic approach to improve chronic disease management.  6.      Identify early barriers to full recovery and early symptom management.  Hall, K. K., Chang, A. B., & O'Grady, K.F. (2016). Discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness (Protocol). Cochrane Database of Systematic Reviews, Issue 8. Art. No.: CD012315. DOI: 10.1002/14651858.CD012315.   Develop Recommendations for Change Based on Evidence The recommendation of this proposal is to implement the program of using individual caseworkers to manage health care plans/discharge plans for pediatric patients who are hospitalized for acute respiratory exacerbations with chronic lung diseases.  Individual assigned case managers will work with caregivers on the discharge plan and disease management plan from admission, throughout hospitalization, discharge, and home management to prevent unplanned hospital readmissions.  Translation Action Plan To implement this proposed program this proposal will be submitted to the hospital readmission committee, the pediatrics medical director, and the director of case management.  A power point presentation will also be presented at the monthly hospital readmission committee meeting.  To implement this program a partnership with pediatrics and the emergency must be obtained.  Education to all staff members of the emergency room and pediatric department must be done so referrals are given, and the case managers are notified of patients.  A partnership and education will be done with hospitalists and primary care pediatricians, so they will support the program.  If they do not partner with the team the program will not be successful.  The hospitalist must work with the case manager when developing the discharge plan and the primary care physician must work with the case manager during the home management phase of the program to ensure proper management of the disease process and prevent a readmission.   The timeline for the plan is one fiscal year with quarterly reports.  How many readmissions each patient had will be monitored.  How many emergency room visits will be monitored.  How many visits to the primary care physician will be monitored?  Compliance with medications will be monitored.  As well as adherence with the program and if the caregiver is using the case manager.  These will be reported in a quarterly report to the primary care physicians, hospitalists, readmission committee, director of care management, and senior leadership.  Process, Outcomes Evaluation and Reporting Individualized case managers managing and coordinating the discharge plan and health care plan of pediatric patients with chronic respiratory diseases from hospital admission, discharge, and home management will decrease hospital readmissions, decrease emergency room visits, decrease adverse reactions, improve relationships with primary provider, improvement of quality of life, cost-effectiveness, and compliance with discharge medications. (Hall, Chang, & O'Grady, 2016) These outcomes will be measured by the case managers who will evaluate each case with a tool sheet.  Admissions, emergency room visits, primary care visits will be tracked and recorded.  These results will be reported quarterly to the previously stated groups including the readmission committee.  The end of the fiscal year a detailed report alone with a presentation with graphs and power point outlining the program, the interventions, and the program results over the course of one year.      Identify Next Steps The next step of this program would be to adapt it to other patient populations and illnesses identified with frequent readmissions.  This program would be easily adaptable to help decrease <30 readmissions with congestive heart failure patients or COPD patients.  To ensure the implementation of this program would require frequent education of staff on the various units affected by the program such as ER and pediatrics.  Also, a continued partnership with the hospitalists, primary care providers, and ER physicians.  For the program to maintain top performance it would also need to be revaluated monthly to see where improvement or tweaking is needed.  Weekly meetings with case managers to discuss how the program implementation is going and discussing any problem areas.  Working with case managers to develop an intervention to improve problem areas within the program.  Disseminate Findings The program findings will be reported internally in total in a quarterly report at hospital readmission committee meetings.  Updates may be given monthly as this meeting as well.  Senior leadership, hospitalists, primary care providers, and case managers may receive quarterly reports and monthly updates via email.  To report the program findings externally at the end of the year in a research paper outlining my entire project and be published in a journal.    Conclusion The Ace Star Model was used in this proposal.  First it began defining the scope of the EBP, by stating the nursing problem was hospital readmissions.  This hospital has a 20% readmission rate.  This means one in five patients will be readmitted.  It was also pointed out that discharge plans are rushed, and the patient or caregiver may not have fully understood it or was unable to execute it.  The stakeholders of this proposal are the team leader, case managers, and an administrative assistant.  These stakeholders will coordinate care for the patient population throughout the hospital stay, upon discharge, and through home management.   Evidence was gathered from literature, financial analysis, expert opinion, and patient preferences.  The evidence presented was strong and concise.  The evidence proved the case management program may reduce hospital readmission of pediatric patients by improving communication with providers, understanding the types of available inpatient and outpatient hospital services to maximize outpatient care, coordinating care from hospital to home, improved health education and promotion, and finally identify early barriers to full recovery and early symptom management.  The recommendation for change based on evidence is to implement the program of using individual case managers to manage health care plans/ discharge plans for pediatric patients who are hospitalized for acute respiratory exacerbations with chronic lung disease.  Care managers will work with caregivers from admission, during hospitalization, discharge and home management.  The action plan is to submit the proposal to the hospital readmission committee, senior leadership, hospitalists, and primary care pediatricians.  The timeline for the plan is one year.  There will be monthly updates given in readmission committee meetings.  Quarterly reports will be sent via email and distributed to leadership, physician, and case managers.  A year end presentation will be given to show the results of the program to which an invitation will be sent to all hospital personnel.  It was identified in this proposal paper that the next steps would be to adapt this program to other patient populations with chronic illnesses who have frequent unplanned hospital readmissions such as congestive heart failure.  To ensure the continued use of this program it must frequently be evaluated, and problems corrected by the team leader and case managers.  Open communication is key.  Consistent education of case managers, staff of pediatrics department, and the emergency department on the program and its benefits.  In conclusion, the use of case manager to coordinate care from admission through home care is a cost-effective way to deliver quality patient centered care while preventing hospital readmissions.  


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