Transitional Care

Transitional care is referred to as a set of activities intended to guarantee the management and stability of health care as unwell individuals transfer between various locations or various levels of care in the similar location (Bauer, Fitzgerald, Haesler & Manfrin, 2009). Agent locations consist of hospitals, nursing facilities, long-term care facility, and the patient’s home. Transitional care is founded on an inclusive plan of care and the accessibility of health care experts who are professionally trained in chronic care and have recent information regarding the goals of the patient, priorities, and clinical status. It involves logistical agreement, patient and kin education, and harmonization amongst the health practitioners involved in the change.

Transitional care, which includes both the sending and the receiving features of the transfer, is fundamental for individuals with compound care needs. Transitional care is planned to assist patients get stronger and be more fully recovered following hospitalization. However, there are situations where transitional care is not achieved due to some failures. Some of which include poor communication between the hospital and the community based care giver, and lack of patient education (Stone & Goeffrey, 2010).

Research Question

Hospital readmission can be avoided if effective measures are put in place. What measures can be implemented so that hospital readmission is reduced for chronically ill patients?  

Research problem establishment

Taxpayers in the United States have had an extra burden due to the health care method. Statistics have shown that, in the coming ten years, this trouble is likely to rise by seventy nine percent. This indicates that over three quarters higher of its present sizes, hence more than five hundred billion dollars a year. Such an enormous raise would definitely compel the government to redirect money from other vital areas to take care of the compulsory Medicare. Twenty nine percent of the Medicare funds cater for inpatient medical expenditures. It is approximated that the expenditure will continue to rise with a yearly projection increase rate of six percent. Majority of these finances are spent for the expense of medical payments for a small figure of patients who have chronic conditions. These patients, majority of them being the elderly, seem to have numerous conditions like coronary diseases and diabetes. Among the various challenges faced in the health care scheme, is standard of care matters. In the report to Congress, within thirty days following discharge from the United States hospitals, one in every five patients become readmitted (Stone & Geoffrey, 2010).

Patients with numerous chronic diseases or conditions are the most affected. This therefore accounts for the rising rates in usage of Medicare finances among this group. Additionally, the group that creates the leading percentage of the readmission cases is the chronically ill patients. However, various readmission situations can be avoided. The assumption here is that the readmission rate is higher among the elderly inpatients following their discharge from the hospitals. This indicates that there is unsatisfactory health care services and lack of appropriate coordination during the procedure of discharge. Amongst the various issues that contribute to readmission of preventable situations, include improper coordination in transition involving the various care providers. This indicates that there is poor connection between the hospital and the succeeding care providers following discharge. More suitably, there is a lack of efficient communication involving the hospitals and community based care givers. Readmission to hospitals can influence the morale of the patient and extend the process of recovery (Ryan, Aloe, & Mason-Johnson, 2009). Additionally, readmission is a strain on the providers of medical care and also the hospitals. As such, it is an issue that requires to be investigated and addressed.

Research Objectives

Multiple issues contribute to preventable hospital readmissions; they may arise from poor standard care or from poor shift involving various givers and care settings. This research is therefore intended to look at the factors that contribute to preventable hospital readmissions. Various studies have indicated that the health care scheme is loaded by compulsory hospital readmissions. Available literature, shows that within thirty days following discharge from hospitals, one in every five sick people discharged get readmitted (Struinin, Stone, & Jack, 2007). In addition, statistics show that the Medicare expenses continue to rise exponentially, with a protrusion of more than seventy percent gain in the coming ten years. This increase has by now overloaded the system of health care and is likely to inflict serious quality matters if not tackled. The research, thus, is planned to develop substitute health care strategies, which can effectively address the issue. Some of these substitute health care strategies include implementing measures which can reduce preventable hospital readmissions. The research also aims at developing ways of reducing hospital readmission while providing a quality health service to patients.

Clinical Strategies

In sensitive care situation, communication policies involve multidisciplinary care series rounds, education of the patient and family, appointments for patients at high possibility for readmission, medication understanding, and discharge planning with community based care providers (Bauer et al., 2009). Knowledge of what happens after discharge is important for both the patient and the health care provider because progress of recovery is easily monitored. Patients in a greater risk group for readmission require a demanding post-discharge involvement plan to minimize readmission. The care giver should plan a home visit in the initial forty eight hours following discharge (Maloney &Weiss, 2009).

For various patients who are discharged from the hospital, returning anytime soon is the last thing they want. However, within thirty days, several Medicare patients leaving an inpatient stay get themselves back in the hospital. According to Maloney & Weiss (2009), a number of these readmissions are intended, while others may be component of the natural way of treatment for particular conditions. Hospitalization is very costly and therefore hospitals try to implement measures that would reduce readmission. These strategies include several home visits instantaneously following discharge, so that proper management can be given to the patients. Other interventions include discharge planning, care transitions, medication understanding, and patient education. Good communication between health care providers is also important. Another clinical strategy is developing a follow-up plan prior to the patient’s discharge (Maloney &Weiss, 2009). The patient should not be released until the plan is set up. This is important because the patient will know the significance of the appointment and the time frame.

Provision of medication on discharge is also a good clinical strategy. A patient should be sent home with a supply of thirty day medication, well wrapped and unmistakably explains dosage, timing, and frequency (Ryan, Aloe &Mason-Johnson, 2009).

Enhanced coordination involving hospitals and community based care providers can significantly decrease readmission of the elderly recurrently ill patients. This will improve a good relation between the patient, health care provider, and the family.

Methodology-Sample Method and Study Design, Data Analysis

A panel of transition care researchers, process enhancement specialists, and hospitalists assembled to review the literature and build up a checklist of procedures and elements needed for perfect discharge of elderly recurrently ill patients. The discharge checklist was given to one of the American hospital, where it was evaluated and revised by various hospital-based nurses, practicing hospitalists, pharmacists, and case managers. The ultimate checklist was approved by the Society of Hospital Medicine. The approved checklist is an inclusive list of the procedures and constituents considered essential for most favorable patient handoff during hospital discharge.

The study will essentially address the issue of readmission amongst the elderly recurrently ill patients. The admission information will, hence, be needed to establish whether people can be categorized in this cluster. Additionally, discharge information will be needed to ascertain the coordination involving the hospitals and community based care providers. Secondary information will essentially be used for this project.

The improvement of substance and procedure standards for discharge is the initial step in promoting the delivery of care from the inpatient to the setting that is post hospital (Ryan et al., 2009). Improving the checklist for patients with particular diagnoses, in particular age groups, and with detailed discharge destinations may additionally refine transfer of information and finally affect the outcome of the patient.

Following the above research, every participant concurred that hospital readmissions are a persistent issue that negatively affect patients, health providers, and payers. Decreasing hospital readmission, hence, needs the participation of every stakeholder. While not every involvement will be comprehensive, enhanced communication, and enhanced hand-offs involving inpatient and outpatient givers which are targeted at decreasing hospital readmission in the Medicare populace may possibly reduce preventable readmissions for the non-Medicare populace. Decreasing hospital readmissions in a split health care scheme needs stakeholders to challenge features of the present system by; improving the relationships involving health care providers, and working to enhance the upcoming system and workforce. Since most hospital readmission take place within thirty days, a thirty day prescription is fundamental to prevent possible readmission. A lack of system elements like harmonized care and flawless communication and data exchange involving inpatient and community based givers, may as well result to unplanned readmission. Continuous discussion, investigation, and experimentation are essential to decrease the number of preventable readmissions and raise the health care value.

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