Readmission to the Hospital

TOPIC:  Readmission to the hospital within 60 days of discharging to Homecare services 

In this discussion,.

• Select a theory and apply it to your chosen nursing intervention. Why did you choose this theory?
• When thinking about how to evaluate (obtain an outcome) its effectiveness, what would you measure? Why did you select the method?
• Include at least 2 scholarly articles supporting your post.

For the topic of hospital readmission within 60 days of discharging to Homecare services, I would select the “Transitional Care Model” (TCM) as the nursing theory to guide the intervention. The TCM was developed by Dr. Mary Naylor and her colleagues and focuses on improving the transition of patients from acute care settings to home or other care settings. This theory is particularly relevant in reducing readmissions by ensuring a smooth transition to homecare services and comprehensive post-discharge support.

Application of Transitional Care Model (TCM):

The TCM involves a comprehensive approach that includes risk assessment, care planning, and coordination of services during the transition from hospital to homecare. In this context, a TCM-based intervention would involve the following elements:

1. Comprehensive Assessment: Using the TCM, nurses would conduct a thorough assessment of the patient’s needs, including medical, social, and environmental factors. This would help identify high-risk patients who are more likely to be readmitted.
2. Customized Care Plans: Based on the assessment, nurses would create customized care plans that address the individual patient’s needs. This may include medication management, symptom management, and support for activities of daily living.
3. Care Coordination: The TCM emphasizes the role of nurse-led care coordination. The nurse acts as a bridge between the hospital and homecare services, ensuring that all healthcare providers are on the same page regarding the patient’s care plan.
4. Patient and Family Education: The TCM also focuses on patient and family education to empower them in managing their health at home. This includes teaching patients about their conditions, medications, and when to seek help.
5. Timely Follow-Up: Scheduled follow-up visits and regular phone calls to monitor the patient’s progress and address any issues or concerns.

Evaluation of Effectiveness:

To evaluate the effectiveness of the TCM-based intervention in reducing hospital readmissions within 60 days, you would need to measure several key outcomes:

1. Readmission Rates: The primary outcome measure would be the rate of hospital readmissions within 60 days of discharge. This can be compared to historical data or a control group that did not receive the TCM intervention.
2. Patient Satisfaction: Assess patient and family satisfaction with the care received during the transition period. This can be done through surveys or interviews.
3. Medication Adherence: Measure the patient’s adherence to prescribed medications, which is crucial for managing chronic conditions and preventing exacerbations.
4. Healthcare Costs: Evaluate any cost savings associated with reduced readmissions. Calculate the cost-effectiveness of the TCM intervention.
5. Quality of Life: Assess the patient’s quality of life and functional status post-discharge. This can be measured using standardized tools.

Scholarly Articles Supporting the Post:

1. Naylor, M. D., & Keating, S. A. (2008). Transitional care: Moving patients from one care setting to another. American Journal of Nursing, 108(9 Suppl), 58-63.
2. Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828.

These articles provide evidence of the effectiveness of transitional care models like TCM in reducing hospital readmissions and improving patient outcomes during the transition from hospital to homecare services.