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Clinical Practice Experience (CPE) Record 5

Phase 1

[Your Name]

Western Governors University

D030: Advancing Evidence-Based Innovation in Nursing Practice

Dr. Course Instructor Name

Month DD, YY
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Clinical Practice Experience (CPE) Record 5

Phase 1:

Effective Transition of Patient Care

CPE Schedule

Phase Task/Activity Due Date Completion

Time
Review activities and components for the paper. 10/18/2021 30 minutes
Create a CPE schedule. 10/18/2021 1 hour
Research the CMS HRRP and discuss its elements. 10/18/2021 1 ½ hour
Develop a care transition plan for the patient with 10/19/2021 1 ½ hour
COPD.
Phase Research evidence on the effective transition from 10/19/2021 2 hours
2 hospital to home.
Discuss evidence-based practices on the prevention 10/20/2021 1 hour
of readmissions.
Evaluate determinants of health consideration 10/20/2021 1 ½ hour
impacting readmissions.
Phase Create strategies for hospitalization prevention at 10/21/2021 2 hours
3 primary, secondary, and tertiary levels.
Record a GoReact video. 10/21/2021 30 minutes
Summarize my reflection. 10/22/2021 30 minutes
Respond to peers’ videos. 10/23/2021 30 minutes
Share a link to the e-portfolio. 10/23/2021 5 minutes

Elements of the CMS HRRP

One key element of care delivery is effective communication and coordination

between providers and their patients. The Centers for Medicare & Medicaid Services’ (CMC)

Hospital Readmission Reduction Program (HRRP) is one essential program that helps

improve provider-patient coordination and communication. HRRP is based on the mandatory

federal pay-for-performance strategy aimed at reducing healthcare costs while enhancing

healthcare outcomes by imposing Medicare reimbursement penalties on facilities with higher

than expected readmission rates (Psotka et al. 2020). The CMS includes six procedure

specific unplanned readmission measures in pneumonia, elective primary total hip

arthroplasty, heart failure, COPD, and acute myocardial infarction. The payment reduction
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and component results are calculated based on a hospital’s performance during a rolling

period (CMS, 2021). The excess readmission ratio (ERR) is used to evaluate hospital

performance. This ratio measures relative performance to predict expected readmission rates.

The ERR is used as a payment reduction methodology.

Patient Introduction and Care Transition Plan

Patient Introduction

Chronic obstructive pulmonary disease (COPD) is one of the key conditions included

in CMS’s HRRP. In developing a care transition plan, Marcia, a 63-year-old female with

COPD and currently being discharged after a 4-day stay for treatment, will be considered.

Marcia has a 12 years history of COPD, hypertension, osteopenia, overweight, and total

hysterectomy. The patient has been experiencing shortness of breath before admission and

has pulmonary rehabilitation has been ordered. She was treated by a hospitalist and has not

been able to wee or make an appointment with the primary care provider, whose availability

is between 3 and 5 weeks after making an appointment.

Care Transition Plan

COPD is a significant health issue, and effective management of the condition is

critical in improving the quality of life of the patients. From the case, Marcia was brought in

due to an increased shortage of breath that progressed to dyspnea at rest and nagging and

hacking cough which may be related to low oxygen supply to the body. Therefore, the goal of

the management is to enhance Marcia’s breathing. Therefore, the BREATH (Better

Respiratory Education and Treatment Help Empower) program is adopted in the transition

process. Marcia has not booked an appointment and is more likely to wait for 3-5 weeks to

see her primary physician. Therefore, in transitioning to home care, the BREATH program is

initiated to improve Marcia’s health-related quality of life and reduce her need for emergency

room healthcare. In this program, a needs assessment was conducted with factors such as
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living alone, lack of support, delays in appointment due to limited physicians, and the

emergency nature of COPD being identified as key drives to frequent hospital visits,

hospitalization, and poor management of the condition.

Marcia was taught on COPD management, including medication adherence, activity,

and rest as well as the way to detect exacerbation. A breathing exercise was initiated to help

patients transition from hospital to normal life involving activities. Pulmonary rehabilitation,

an exercise and self-management strategy for patients with COPD (Miranda et al. 2020), was

initiated to help Marcia cope independently with COPD as she lives alone. Follow-up home

visits and phone calls were made to determine COPD management and the effectiveness of

the treatments. In improving Marcia’s outcomes, she was connected with community services

and programs for smoking cessation, transportation, and peer support including hotlines.

In transitioning to home care, social support is one of the factors that affected the

success of the transition process as Marcia has no family members living with her. She also

lacks a house help reducing her social support increasing her level of fear and nervousness

about going home. Physical and mental health is another factor that affects transition and as

described by a patient’s health, will determine the success of the transition from hospital to

home care (Miranda et al. 2020). In the case of Marcia, her increased lung function and better

breathing improved her energy conservation promoting her transition.

Phase 2:

Prevention of Hospital Readmission

Preventing All-Cause Hospital Readmissions

Hospital readmissions can be avoidable and unavoidable. Healthcare providers and

organizations must identify the most appropriate strategies for preventing avoidable

admissions. High rates of 30-day hospital readmissions, as described by CMS (2021), are an
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indicator of quality issues and Medicare penalized hospitals for these rates. Care transition

processes reduce these readmissions as there were lower risk standardized readmission rates

(RSRR). According to Pugh et al. (2021), patient inclusion in the discharge planning is

important in ensuring that they understand and collaborate in creating discharge instructions.

Such an approach enhances their adherence to these instructions. Patient involvement in their

care enhances patient-centered care which in turn improves compliance and productive

collaboration and coordination between providers and patients. Patient involvement in the

discharge planning is essential in ensuring that their specific needs and concerns are

addressed promoting self-management desires.

One key factor that increases readmission rates is poor discharge information and lack

of adequate discharge training. For people with chronic conditions such as heart failure or

COPD, proper patient education would have a significant positive impact in promoting

treatment adherence and lifestyle modifications reducing adverse health outcomes. Miranda

et al. (2020) found that providing patients with COPD the skills and training on self-

management including behavior change, emotional support, and disease-specific treatment,

may improve care outcomes reducing readmission rates. Lack of adequate training and

education on disease including the symptoms, exacerbations, management, and treatment,

may encourage poor management of the condition leading to high hospital visits and

consequent hospitalizations. Therefore, improving patient health education related to a

specific condition during transition and discharge is important in preventing readmissions.

Increased use of community support systems such as peer groups, counseling

services, and smoking cessation programs may help the patient cope with a condition

improving their overall management capacity for these conditions. Miranda et al. (2020)

affirm that social support programs within the community are essential in improving a

patient’s self-management skills once the patient has transitioned to home care. Support
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programs provide essential services and guidance to patients enabling them to cope with a

condition and consequentially improving their overall experiences and willingness to enhance

their self-management of these conditions. Rather than rely entirely on healthcare

organizations and providers to guide them on appropriate care, patients can use these services

to improve their health outcomes.

Patient follow-up programs including home visits and follow-up phone calls, are also

important in reducing readmissions. According to Nair et al. (2020), follow-up appointments

are critical in identifying and addressing key areas of concern through the care continuum

leading to a substantial reduction in readmission rates. When a patient transitions from

hospital to home care, healthcare providers must maintain continuous communication and

data sharing with the patients to promote patient-centered care. Portillo et al. (2018) indicate

that timely access to follow-up services is associated with a significant decline in rates of

hospital readmissions as they foster complete medication reconciliation, effective patient

provider communication, and quicker response to emergencies.

Social determinants of Health Considerations

Social determinants of health are the conditions in which an individual or a group of

people is born, work, age, live, grow, and a wife set of systems and forces that influence daily

life conditions. These factors are responsible for most health disparities as they are rooted in

global, national, and local resource allocations. According to Obuobi et al. (2021), these

social determinants of health (SDOH) have significant implications on health outcomes

including readmission rates. Therefore, when seeking to address or prevent readmission rates,

including these factors in the readmission algorithm may improve their predictive accuracy.

Individual SDOH like ethnicity, sex, marital status, old age, and primary language

significantly affect readmission rates (Zhang et al. 2020). For instance, Spanish with limited

English may experience challenges comprehending instructions given in English which may
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lead to poor self-management thereby higher rates of readmissions than a native English

speaker. Equally, for married individuals, there is a high likelihood of lower readmission

rates as they have social support from their spouses which improves their health outcomes

instead of individuals living alone.

Community SDOH such as socioeconomic status, income inequality, neighborhood,

and safety are also important determinants of readmission rates and associated prevention.

According to Zhang et al. (2020), poverty is associated with higher levels of readmission

rates as poor people are unable to access basic services and products that would improve their

self-management. For instance, Marcia receives $15,800 per yare and cannot afford her

transport which limits her ability to self-care and access the basis services. Additionally,

neighborhood affects an individual capacity to engage in required lifestyle changes like

exercise (Zhang et al. 2020). For instance, Marcia lives in a neighborhood with broken

sidewalks, far away from grocery stores, and no parks. These undesirable SHOH adversely

affect the patient’s capacity to self-care increasing their risk for readmission.

Phase 3:

Hospital Prevention Plan

Hospitalization is associated with lower hospital scores leading to penalties, and

management will always strive to reduce hospitalization to meet Medicare performance

scores. While HRRP focuses on instituting penalties to hospitals for not meeting readmission

standards and for high preventable readmission rates, hospitalization can be prevented

thereby improving the overall performance of an organization. These hospitalizations can be

prevented at the primary, secondary, or tertiary level.

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Primary Prevention

Primary prevention focuses on preventing an event or a health effect before it occurs

by altering risk behaviors, vaccination, and banning substances that lead to adverse outcomes.

A key strategy for preventing avoidable hospitalization is through patient education, which

aims at providing patients with adequate information to help them manage healthcare issues

at home and reduce their risks for adverse outcomes (Warchol et al., 2019). For instance, for

a patient with COPD, education on healthy eating habits, smoking cessation, activity, and

medication adherence is critical in preventing potential hospitalization.

Secondary Prevention

While primary prevention of hospital readmission focuses on equipping patients with

information and skills to enable them to manage their health at home, secondary interventions

focus on identification of the problems at early stages and initiating strategies to address the

problems. In preventing hospitalization at the secondary level, follow-ups including phone

calls and home visits, are important. According to Portillo et al. (2018), timely access to

follow-up care at the time of transition improves care coordination reducing hospital visits,

improves the quality of care, and promotes outpatient care outcomes. These virtual or face-to-

face visits improve home care outcomes which reduces the probability of adverse health

outcomes.

Tertiary Prevention

At this level, the objective is to improve the patient's quality of life and reduce the

frequency of admission. Some of the key strategies for preventing readmission for people

with COPD are post-acute services like rehabilitation and monitoring readmission rates. Post-

acute services for a patient at home care may include ongoing outpatient therapy which

focuses on providing specialized healthcare services at the patient’s place. This reduces

hospitalization as the patient is localized at home or within the community. On the other
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hand, monitoring readmission rates may help an organization understand its patient

population allowing healthcare providers to deploy targeted interventions to reduce

readmissions (Warchol et al. 2019). These strategies enhance the management of COPD and

other conditions, improving the overall organizational goal of minimizing preventable

readmissions.
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References

Centers for Medicare & Medicaid Services (2021). Hospital readmission reduction program

(HRRP). CMS.gov. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/31423116/

Miranda, J., Underwood, D., Kuepfer-Thomas, M., Coulson, D., Park, A. C., Butler, S. J.,

Goldstein, R., Brooks, D., Everall, A. C., & Guilcher, S. (2020). Exploring transitions

in care from pulmonary rehabilitation to home for persons with chronic obstructive

pulmonary disease: A descriptive qualitative study. Health expectations: an

international journal of public participation in health care and health policy, 23(2),

414–422. https://doi.org/10.1111/hex.13012

Nair, R., Lak, H., Hasan, S., Gunasekaran, D., Babar, A., & Gopalakrishna, K. V. (2020).

Reducing All-cause 30-day Hospital Readmissions for Patients Presenting with Acute

Heart Failure Exacerbations: A Quality Improvement Initiative. Cureus, 12(3), e7420.

https://doi.org/10.7759/cureus.7420

Obuobi, S., Chua, R. F., Besser, S. A., & Tabit, C. E. (2021). Social determinants of health

and hospital readmissions: Can the HOSPITAL risk score be improved by the

inclusion of social factors? BMC health services research, 21(1), 1-8.

https://doi.org/10.1186/s12913-020-05989-7

Portillo, E. C., Wilcox, A., Seckel, E., Margolis, A., Montgomery, J., Balasubramanian, P.,

Abshire, G., Lewis, J., Hildebrand, C., Mathur, S., Bridges, A., & Kakumanu, S.

(2018). Reducing COPD Readmission Rates: Using a COPD Care Service During

Care Transitions. Federal practitioner: for the health care professionals of the VA,

DoD, and PHS, 35(11), 30–36.

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Psotka, M. A., Fonarow, G. C., Allen, L. A., Joynt Maddox, K. E., Fiuzat, M., Heidenreich,

P., ... & O'Connor, C. M. (2020). The Hospital Readmissions Reduction Program:

nationwide perspectives and recommendations: a JACC: Heart Failure position paper.

JACC: Heart Failure, 8(1), 1-11. https://doi.org/10.1016/j.jchf.2019.07.012

Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., ... & Leykum, L.

(2021). Evidence based processes to prevent readmissions: more is better, a ten-site

observational study. BMC Health Services Research, 21(1), 1-11.

https://doi.org/10.1186/s12913-021-06193-x

Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W. W. (2019). Strategies to Reduce

Hospital Readmission Rates in a Non-Medicaid-Expansion State. Perspectives in

health information management, 16(Summer), 1a.

Zhang, Y., Zhang, Y., Sholle, E., Abedian, S., Sharko, M., Turchioe, M. R., Wu, Y., &

Ancker, J. S. (2020). Assessing the impact of social determinants of health on

predictive models for potentially avoidable 30-day readmission or death. PloS one,

15(6), e0235064. https://doi.org/10.1371/journal.pone.0235064