Plans to Decide the Future of Your Solution
This evidence-based practice method will be implemented as a proposed solution to decreasing heart failure (HF) readmission rates. Transitional care activities ensure health care continuity, reduce risk of poor health outcomes, and facilitate safe transfer between levels of care or health care settings (Naylor et al., 2011).
Methods and Specific Plans to Maintain a Successful Project Solution Methods and Specific Plans to Extend a Successful Project Solution
This proposal will be implemented as a pilot program between the Heart Hospital and the Norfolk branch of the home care agency. If this transitional care program is successful in reducing HF readmission rates, additional sites will be given the opportunity to participate. Preference will be given to those agency locations that have a large HF population served by the Heart Hospital. The project team will reach out to the branch administration and clinical educators to share program details and current data related to readmission rates as a result of program implementation. The team will also assess whether this program proposal is feasible at other hospitals within the health system.
The team will gather input from hospital administrators and the informatics department to decide which hospitals would be best suited to pilot this program. In addition, there must be a home health agency that is part of the system located within 25 miles of the hospital. The end goal of this proposal is to achieve system wide implementation of the transitional care program at all 12 acute care facilities and 19 home health branches in Virginia.
Methods and Specific Plans to Revise an Unsuccessful Project Solution
Ongoing monitoring of the transitional care program for HF readmissions will be performed by the representatives of the hospital and home health agency. On the hospital side, a clinical nurse specialist on the cardiac unit and a program analyst will ensure that referrals are made to appropriate patients and discharge plans include the transitional care activities. On the home health side, the Norfolk branch team leader, clinical informaticist, and information technology data specialist will monitor program operations. This team will collaborate closely to ensure that program implementation is successful. If the program is not yielding the expected outcomes then a strengths, weaknesses, opportunities, and threats (SWOT) analysis will be performed.
All barriers identified will be addressed in a timely manner and changes may be made to the initial plan to promote success. In addition, staff and patients will be surveyed to ascertain challenges not readily apparent to the implementation team. These surveys will be designed and conducted by the clinical education department for the hospital and home health agency. The timeframe for conducting patient surveys will occur within seven days of admission into the program and then every 60 days. Since patients will need to be reassessed every 60 days for continuation of home health services, it is feasible to conduct the transitional care program survey concurrently.
The team reserves the right to conduct additional patient surveys if a patient is readmitted to the hospital at any time during program participation or opts out of the transitional care program. Staff at the hospital and home health agency will be surveyed 90 days from their training date on the transitional care program and then every six months. Results of these surveys will be shared with the project team implementation coordinators during the monthly team meeting. Methods and Specific Plans to Terminate an Unsuccessful Project Solution Specific Plans for Feedback in the Work Setting and for Communicating the Project and its Results to Professional Groups External to the Project Conclusion
Despite its high prevalence, HF care is often fragmented and uncoordinated. The transitional care program proposed by the team seeks to address these gaps in care and to reduce HF readmission rates.
Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practices. (2nd ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Retrieved from University of Phoenix eBooks. Russell, D., Rosati, R.J., Sobolewski, S., Marren, J., & Rosenfeld, P. (2011). Implementing a transitional care program for high-risk heart failure patients: Findings from a community- based partnership between a certified home healthcare agency and regional hospital. Journal for Healthcare Quality, 33(6), 17-24. Retrieved from EBSCOhost.
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