The prospective payment system (PPS) provides reimbursement based upon patient diagnosis. Other areas of concern for reimbursement include chronic conditions outside of the acute scenario. Health systems are highly regulated around readmissions and timely follow-ups. Choose a disease state that complicates early readmission and adapt three areas of intervention to enhance the wellness of the patient population. Discuss specific AGACNP initiatives that could improve patient outcomes, reduction in the incidence of early readmission, and avoidance of increased length of stay (LOS). Refer to published doctoral dissertation, “Associations Between Control of Glucose, Diabetes Support Services, New Insulin Initiation and 30 Day Hospital Readmission in Diabetes Patients,” located in the study materials, as a resource for this discussion question.
Heart failure (HF).
Heart failure (HF) is a complex, relapsing, severe chronic disease-causing multisystem dysfunction resulting in high morbidity, mortality, and healthcare costs. HF is cited as one of the most frequent reasons for hospitalization in the US and Europe and approximately 26 million people worldwide are affected by chronic HF (Jermyn, Alam, Kvasic, Saeed, & Jorde, 2017). A multidisciplinary team approach is considered the gold standard model for the delivery of HF care (Morton, Masters, & Cowburn, 2018). HF care recognizes the complexity and various aspects of the illness to provide individualized, holistic care for the changing needs of patients throughout the course of the illness, seamless transition of primary and secondary care meaning receiving the right care from the right person at the right time. The three interventions to enhances the wellness of the HF population were: 1. HF disease modification through drug therapies per guideline-directed medical care and device therapies. 2. Monitoring, education and counseling and follow up of signs and symptoms, daily weights, and other implanted device-based technologies with frequent communications.3. Management of complications, lifestyle modification, and prevention measures. AGACNP’s role in improving patient outcomes, reducing early readmission in HF was the identification of patients requiring cardiac evaluation with echocardiography and other tests and procedures for the progress of therapy, regulation, and control of blood pressure, diabetes, atrial fibrillation, and other comorbidities in heart failure patients (Choi, Park, & Youn, 2019) per 2017 updated guidelines, risk factor modification by and motivational interview, guidance, counseling, follow up, communication and education on disease and therapy.
Morton, G., Masters, J., & Cowburn, P. J. (2018). Multidisciplinary team approach to heart failure management. Heart, 104(16), 1376-1382. Retrieved from https://heart.bmj.com/content/104/16/1376.abstract
Jermyn, R., Alam, A., Kvasic, J., Saeed, O., & Jorde, U. (2017). Hemodynamic‐guided heart‐failure management using a wireless implantable sensor: Infrastructure, methods, and results in a community heart failure disease‐management program. Clinical cardiology, 40(3), 170-176. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1002/clc.22643
Choi, H. M., Park, M. S., & Youn, J. C. (2019). Update on heart failure management and future directions. The Korean journal of internal medicine, 34(1), 11. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6325445/
Chronic Obstructive Pulmonary Disease (COPD) is one of the top reasons for readmissions to the hospital for exacerbations. Majority of the cases are caused by cigarette smoke followed by occupational exposures, genetic factors, and indoor/outdoor exposures. Once COPD has been diagnosed the goals of treatment include managing symptoms, preventing disease progression and exacerbations, and reducing premature mortality.
Interventions that can help improve the wellness of the population with COPD are:
1. Diagnose early and start disease/symptom management.
2. Provide education through pulmonary rehabilitation programs and making sure patients follow up.
3. Help patient make lifestyle changes to improve wellness
COPD still remains underdiagnosed or the diagnosis is made once the disease is advanced. AN early diagnosis would improve patient outcomes such as smoking cessation earlier and getting on medications to prevent the advancement (Koblizek, et al., 2016). Lifestyle influences our health and our overall morbidity and mortality. These changes such as smoking cessation, increasing physical activity, improving diet, and avoiding the irritants that trigger exacerbations will help improve overall health of the patient (Ambrosino & Bertella, 2018). Smoking cessation is the first thing a patient should do once diagnosed because it alone is a risk that reduces life expectancy and this can be helped with nicotine replacement therapy or behavioral therapy. Increasing physical activity is another great way to improve overall health because a sedentary lifestyle is not healthy and reduces life expectancy as well. There are exercise training programs that help improve symptoms and improve quality of life (Ambrosino & Bertella, 2018). Nutrition is overall a way to manage any disease, but in COPD certain foods can increase the exacerbation by increasing mucous production. If a patient doesn’t eat a well-balanced diet it can trigger exacerbations while increasing fruits and vegetables can improve the symptoms. Pulmonary rehabilitation can help individuals lead a more active lifestyle, reduce symptoms, and improve quality of life. The education portion of disease management is very important so the patient understands the disease process, how to manage it, and how to improve quality of life Rinne, et al., 2018). The more interdisciplinary care and education provided the better tools a patient has to manage the disease. The AGACNP can help make the early diagnosis and referrals to rehabilitation so the patient has improved outcomes. The practitioner can stay up-to-date on the gold standard for diagnosis and screening patients that are at a higher risk for the disease to help facilitate the early interventions (Gustafsson & Nordeman, 2018).
Ambrosino, N., & Bertella, E. (2018). Lifestyle interventions in prevention and comprehensive management of COPD. Breathe (Sheffield, England), 14(3), 186–194. https://doi.org/10.1183/20734735.018618
Gustafsson, T., & Nordeman, L. (2018). The nurse’s challenge of caring for patients with chronic obstructive pulmonary disease in primary health care. Nursing open, 5(3), 292–299. https://doi.org/10.1002/nop2.135
Koblizek, V., Novotna, B., Zbozinkova, Z., & Hejduk, K. (2016). Diagnosing COPD: advances in training and practice – a systematic review. Advances in medical education and practice, 7, 219–231. https://doi.org/10.2147/AMEP.S76976
Rinne ST, Lindenauer PK, Au DH. Intensive Intervention to Improve Outcomes for Patients With COPD. JAMA. 2018;320(22):2322–2324. doi:10.1001/jama.2018.17508
Heart failure (HF) is a widespread problem affecting approximately 5.7 million American adults. Of the HF patients hospitalized who have Medicare, 67.4% experienced readmission, and 35.8% died within one year of hospitalization. The risk for readmission is the highest three days post-discharge, and the risk decreased by 50% only after 38 days post-discharge. HF patients also show an elevated risk of readmission for at least one-year post-discharge (Macchio, Farrell, Kumar, Illyas, Barnes, Patel, Silverman, Le, Siddique, Raminfard, Tofano, Sokol, Haggerty, Kaell, Rabbani, & Faro, 2020). The initiative that I will adapt as a future AGACNP in order to improve patient outcomes, reduce the incidence of early readmission, and avoid the increased length of inpatient hospital stay on this specific patient population are the following:
Provision of improved patient and caregiver education at discharge. Education is a vital component of improving outcomes in heart failure. The provision of a structured system of patient and family education that involves a multidisciplinary team and emphasizes medication adherence, sodium and fluid restrictions, and recognition of signs and symptoms that indicate the progression of the disease may be as important as ensuring that patients are prescribed appropriate medical therapy (Macchio et al., 2020).
Facilitate one-on-one meetings between the patient and the hospital pharmacist one day before discharge to review the current medication. One study (Macchio et al., 2020) of patients admitted for HF, acute coronary syndrome, or pneumonia found that most HF patients were not aware of medication changes at discharge, and 63.1% had no understanding of all intended medication changes at discharge. Nearly 25% of medication changes are suspected provider errors secondary to inadequate medication reconciliation. A 2016 systematic review found evidence that pharmacist-led processes could prevent medication discrepancies and potential adverse drug effects (ADEs) at hospital admission, in-hospital transitions of care, and hospital discharge. A 2013 systematic review published as part of the AHRQ Making Health Care Safer II report also found that pharmacist engagement in medication reconciliation prevented discrepancies and potential ADEs after discharge (“Medication Reconciliation”, 2019).
The third initiative is the patient’s referral to the partnered community-based cardiologist for post-discharge follow-up care. One of the factors potentially contributing to continued poor outcomes for patients after an HF exacerbation is care fragmentation. Macchio et al. (2020) found that specific strategies, including partnering with community physicians and health systems, helped reduce readmission rates.
Macchio, P., Farrell, L., Kumar, V., Illyas, W., Barnes, M., Patel, H., Silverman, A.L., Le, T.H., Siddique, H., Raminfard, A., Tofano, M., Sokol, J., Haggerty, G., Kaell, A., Rabbani, S., & Faro, J.(2020). 30-day readmission prevention program in heart failure patients (RAP-HF) in a community hospital: creating a task force to improve performance in achieving CMS target goals. Journal of Community Hospital Internal Medicine Perspectives, 10(5), 413–418. https://doi-org.lopes.idm.oclc.org/10.1080/20009666.2020.1800910
Medication Reconciliation (2019). Retrieved from https://www.psnet.ahrq.gov/primer/medication-reconciliation
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