NR 706 Week 4 Information Systems Translation Science Project Guidelines.

NR 706 Week 4 Information Systems Translation Science Project Guidelines.

Student Name

Chamberlain University

NR-706: Healthcare Informatics & Information Systems

Prof. Name

Date

Introduction

Hospital readmissions in post-acute care facilities continue to be a major concern as they compromise patient outcomes and impose significant financial strain on the healthcare system. Patients who are readmitted face a higher risk of complications, including malnutrition, cognitive decline, recurrent falls, delayed recovery, and in some cases, mortality. In the United States, more than 16,000 skilled nursing facilities (SNFs) provide services to approximately 1.35 million individuals each year. These facilities offer a range of services such as skilled nursing, rehabilitation, and assistance with both activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Centers for Medicare & Medicaid Services [CMS], 2019).

Although many residents transition into long-term care, a significant number are admitted to SNFs for short-term rehabilitation before returning home, often supported by home health services. Despite these transitions, the burden of hospital readmissions remains substantial. Such readmissions delay recovery, increase healthcare costs, and expose patients to preventable health risks (CMS, 2019).

Table 1

Contributing Factors and Their Impact on Patient Outcomes

These outcomes highlight the necessity of implementing evidence-based interventions that can proactively reduce hospital readmissions in post-acute care settings.

Practice Problem and Question

Data indicate that patients discharged to SNFs experience a readmission rate of 17.8%, compared to 15.8% among those discharged directly home (UpToDate, 2019). Considering the 35 million annual hospital discharges in the United States, these unplanned readmissions represent approximately $15–20 billion in healthcare costs each year.

Although Medicare policies and financial penalties have motivated improvements, readmission rates remain troublingly high. Between 2003 and 2007, nearly 20% of Medicare beneficiaries were readmitted within 30 days of discharge (UpToDate, 2019). These statistics emphasize the urgent need to align clinical practice with evidence-based guidelines to minimize unnecessary hospitalizations.

As a Doctor of Nursing Practice (DNP) scholar, the key responsibilities include identifying and addressing gaps between clinical guidelines and real-world practice, designing and testing evidence-based interventions to minimize preventable readmissions, and enhancing patients’ quality of life by improving post-acute care delivery models.

Practice Question

In post-acute care, how does frequent rounding and oversight by clinical providers on newly admitted patients, compared to the current guideline recommendations, influence hospital readmission rates over an 8-week period?

Currently, CMS recommends provider visits every 30 days or as clinically necessary. In contrast, acute care hospitals conduct daily multidisciplinary rounds that enable early detection of complications. In SNFs, infrequent provider supervision often leads to delayed recognition of health deterioration and unnecessary hospital transfers (CMS, 2019). Increasing provider rounds to two or three times per week may facilitate earlier detection of complications, support timely interventions, and effectively reduce readmissions.

Evidence Synthesis of Literature to Address the Selected Practice Problem

A comprehensive review of literature identified several effective strategies for lowering readmission rates. The studies summarized below provide key insights into evidence-based approaches relevant to post-acute care.

Table 2

Summary of Selected Studies on Readmission Reduction

Summary of Evidence

Collectively, these studies demonstrate that improving monitoring practices, enhancing staffing levels, incorporating telehealth, and adopting value-based care models can significantly lower readmission rates and improve patient safety in SNFs.

Appraisal of the Evidence

The reviewed studies primarily provide Level III evidence, reflecting good-quality research with meaningful implications for clinical practice. While some limitations exist—such as small sample sizes and diverse study designs—the consistent findings across studies support a multifaceted approach to reducing readmissions.

A major strength of these studies is their real-world applicability and interdisciplinary focus. Nonetheless, there remains a gap in large-scale randomized controlled trials examining the direct impact of frequent provider rounding in SNFs. Addressing this gap should be a priority for future research.

Translation Path

The successful implementation of these interventions depends on addressing several barriers, including staffing shortages, limited financial resources, regulatory constraints, and patient non-adherence. A collaborative, team-based strategy is crucial for overcoming these challenges effectively.

Application of Lewin’s Change Model

Table 3

Implementation of Lewin’s Change Model

Anticipated Outcomes

The proposed approach is expected to achieve several outcomes, including reduced hospital readmission rates, improved patient safety and functional recovery, stronger care coordination among healthcare providers, and the long-term sustainability of evidence-based practices.

Conclusion

Post-acute care facilities play a vital role in supporting recovery following hospitalization. However, persistently high readmission rates undermine care quality and strain healthcare resources. Evidence indicates that frequent provider rounding, adequate staffing, telehealth integration, and participation in value-based care initiatives are effective in mitigating these challenges.

As a DNP-prepared nurse, advocating for and implementing these evidence-based interventions is essential for achieving sustainable improvements in patient safety, quality of life, and cost-effective care delivery within post-acute settings.

References

Agarwal, D., & Werner, R. M. (2018). Effect of hospital and post-acute care provider participation in accountable care organizations on patient outcomes and Medicare spending. Health Services Research, 53(6), 5035–5056. https://doi.org/10.1111/1475-6773.13023

Burke, R. E., Jones, C. D., Hosokawa, P., Glorioso, T. J., Coleman, E. A., & Ginde, A. A. (2020). Influence of transitional care interventions on hospital readmissions: A meta-analysis. Journal of General Internal Medicine, 35(7), 2084–2093. https://doi.org/10.1007/s11606-020-05715-2

Centers for Medicare & Medicaid Services (CMS). (2019). Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR). https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2801

Dadosky, A., Overbeck, H., Barbetta, L., Bertke, K., Corl, M., Daly, K., … Menon, S. (2018). Telemanagement of heart failure patients across the post-acute care continuum. Telemedicine and e-Health, 24(5), 360–366. https://doi.org/10.1089/tmj.2017.0058

Harris, C., Garrubba, M., Melder, A., Voutier, C., Waller, C., King, R., & Ramsey, W. (2018). Sustainability in health care by allocating resources effectively (SHARE) 8: Developing, implementing and evaluating an evidence dissemination service in a local healthcare setting. BMC Health Services Research, 18(1), 151. https://doi.org/10.1186/s12913-018-2958-3

Hatipoğlu, U., Wells, B. J., Chagin, K., Joshi, D., Milinovich, A., & Rothberg, M. B. (2018). Predicting 30-day all-cause readmission risk for subjects admitted with pneumonia at the point of care. Respiratory Care, 63(1), 43–49. https://doi.org/10.4187/respcare.05719

Kim, H., Park, J., & Kang, H. (2021). Telehealth interventions for reducing hospital readmissions in chronic disease: A systematic review and meta-analysis. International Journal of Nursing Studies, 118, 103923. https://doi.org/10.1016/j.ijnurstu.2021.103923

Manchester, J., Gray-Miceli, D. L., Metcalf, J. A., Paolini, C. A., Napier, A. H., Coogle, C. L., & Owens, M. G. (2014). Facilitating Lewin’s change model with collaborative evaluation in promoting evidence-based practices of health professionals. Evaluation and Program Planning, 47, 82–90. https://doi.org/10.1016/j.evalprogplan.2014.08.007

March, P. P., & Mennella, H. D. A.-B. (2018). Quality improvement in long-term care. CINAHL Nursing Guide. EBSCOhost. https://search.ebscohost.com

McBride, S., & Tietze, M. (2018). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (2nd ed.). Springer Publishing.

NR 706 Week 4 Information Systems Translation Science Project Guidelines.

Ouslander, J. G., & Grabowski, D. C. (2020). Reducing hospitalizations from skilled nursing facilities. Health Affairs, 39(11), 1859–1866. https://doi.org/10.1377/hlthaff.2020.00724

UpToDate. (2019). Hospital discharge and readmission. https://www.uptodate.com/contents/hospital-discharge-and-readmission

Wang, Z., Yuan, Y., Guo, Y., & Li, H. (2022). The effectiveness of nurse-led transitional care programs in reducing hospital readmissions: A systematic review and meta-analysis. BMC Nursing, 21, 51. https://doi.org/10.1186/s12912-022-00832-9