D117 Care Plan for Transition- Phase 1
Student Name
Western Governors University
D117 Advanced Health Assessment for the Advanced Practice Nurse
Prof. Name
Date
Overview of the CMS Hospital Readmissions Reduction Program
In 2012, federal legislation required the Centers for Medicare and Medicaid Services (CMS) to launch a value-based purchasing initiative aimed at improving patient outcomes through better communication, discharge planning, and care coordination. This initiative, called the Hospital Readmissions Reduction Program (HRRP), ties hospital reimbursements to performance metrics focused on reducing preventable readmissions within 30 days of discharge (Centers for Medicare & Medicaid Services [CMS], 2023). The central goal of HRRP is to lower avoidable readmissions by encouraging hospitals to implement evidence-based transitional care strategies that actively involve patients and their caregivers during the discharge process.
CMS evaluates hospital performance in six specific clinical categories under HRRP: acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA). Hospitals with readmission rates higher than expected benchmarks face payment penalties of up to 3%. Although this penalty may seem small, it represents a significant financial and reputational driver for hospitals to analyze readmission causes and enhance discharge planning.
Why is Transitional Care Planning Crucial in Reducing Readmissions?
Unplanned hospital readmissions often result from multiple factors, frequently tied to systemic issues rather than unavoidable disease progression. Common causes include poor communication among healthcare providers, medication errors, lack of follow-up care, and insufficient patient education. According to Feigenbaum et al. (2012), missed opportunities in transitional care planning, medication management, follow-up logistics, and multidisciplinary coordination play major roles in 30-day readmissions. These findings highlight that structured transitional care plans, when effectively implemented, can significantly reduce preventable readmissions.
Elective primary total hip arthroplasty (THA) is one such condition targeted by HRRP. Healthcare teams are expected to apply standardized, evidence-based transitional care plans for all THA patients, regardless of discharge destination—home or skilled nursing facilities. Because THA is elective, many post-discharge complications are foreseeable and therefore avoidable through proactive care planning.
What are the Common Clinical Risks and Causes of Readmission after Total Hip Arthroplasty?
Patients undergoing total hip arthroplasty are at risk for several postoperative complications that may cause unplanned readmissions. Kurtz et al. (2018) identified surgical site infections, atrial fibrillation, pulmonary embolism, septicemia, and pneumonia as the most frequent causes. These complications emphasize the importance of patient education, close monitoring, and timely follow-up during the transition from hospital to home.
The following table summarizes common complications after THA and strategies to prevent them:
| Potential Complication | Risk Factors | Preventive Strategies |
|---|---|---|
| Surgical site infection | Obesity, diabetes, poor wound care | Antibiotic adherence, wound hygiene education |
| Deep vein thrombosis / pulmonary embolism | Immobility, obesity | Anticoagulation, early ambulation |
| Pneumonia | Reduced mobility, shallow breathing | Incentive spirometry, ambulation |
| Joint dislocation or injury | Improper movement, unsafe home | Joint precautions, home safety modifications |
| Medication-related adverse events | Polypharmacy, allergies | Medication reconciliation, patient education |
Patient Case Scenario: Susan
Susan is a 68-year-old woman diagnosed with advanced osteoarthritis who requires elective total hip arthroplasty. She has multiple comorbidities, including obesity (BMI 36.9 kg/m²) and depression. These health factors not only necessitate surgery but also increase her likelihood of postoperative complications and hospital readmission.
What is the Role of the APRN in Preventing 30-Day Readmission?
The Advanced Registered Nurse Practitioner (APRN) plays a vital role in managing Susan’s discharge plan and reducing her risk of readmission. A major focus is infection prevention. Susan must complete her prescribed oral antibiotics following surgery. Because of a penicillin allergy, clindamycin is an appropriate substitute, but since it can cause Clostridioides difficile infection, the APRN must educate Susan to recognize symptoms like persistent or bloody diarrhea early.
Susan should receive detailed instructions on keeping the surgical site clean and immediately reporting any signs of infection—such as redness, warmth, swelling, pain, or drainage. Reinforcement of directing postoperative concerns to the orthopedic surgeon is critical, as continuity of care remains with the surgical team until formal discharge.
How Should Medication Management and Anticoagulation Be Handled?
Medication reconciliation is crucial for preventing adverse drug events and ensuring smooth care transitions. Susan should be discharged with a complete medication list that is shared with her and her primary care provider, clearly detailing drug names, dosages, schedules, and purposes.
To minimize the risk of blood clots, Susan should follow a prophylactic regimen including daily low-dose aspirin, injectable enoxaparin until the course is completed, and regular ambulation. Pain should be managed using a multimodal approach incorporating NSAIDs, opioids as needed, and scheduled acetaminophen to promote mobility and avoid complications from immobility.
What Nutritional and Weight Management Strategies Are Recommended?
Susan’s obesity poses additional challenges to her recovery and long-term joint health. Initially, she should consume a soft, bland diet, gradually advancing as tolerated. A balanced, protein-rich diet is vital to support wound healing and tissue repair. Once recovery is underway, her primary care provider should guide sustainable weight management to reduce joint stress and prevent further musculoskeletal degeneration.
How Can Mobility, Physical Therapy, and Home Safety Be Optimized?
To prevent injury to the new joint, strict adherence to hip precautions taught during inpatient physical therapy is necessary. Susan and her family should be educated on safe movement and home modifications to reduce fall risks. Recommended safety interventions include removing clutter, installing raised toilet seats, using shower chairs, and employing pillows or bed risers.
Durable medical equipment such as walkers and continuous passive motion (CPM) machines should be delivered before discharge. Outpatient physical therapy appointments must be scheduled in advance, with transportation arranged to ensure compliance.
How Can Pulmonary Complications Be Prevented?
Pulmonary issues are another preventable cause of readmission after THA. Susan should be encouraged to use incentive spirometry, practice deep breathing and coughing exercises, stay well hydrated, and ambulate frequently. These interventions reduce the risk of atelectasis and pneumonia. Clear, easy-to-understand written instructions should be provided to reinforce adherence.
How Does Multidisciplinary Discharge Planning and Social Support Affect Readmission Risk?
Before discharge, Susan should be assessed by a multidisciplinary team including physical therapy, occupational therapy, and social work to confirm home safety. Social determinants such as access to transportation, medication refills, grocery shopping, and family support must be considered. Insufficient logistical support significantly increases the risk of readmission.
How Was the Care Plan Reviewed and Improved?
This transitional care plan was reviewed by MaryEllen Kopp, APRN, a postsurgical cardiac advanced practice provider. She stressed the importance of multidisciplinary clearance for discharge, heightened monitoring for Clostridioides difficile infection, and clear education on wound infection symptoms. These recommendations enhanced the clinical relevance and quality of the care plan and will guide future phases of this academic work.
References
Centers for Medicare & Medicaid Services. (2023). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
Feigenbaum, P., Neuwirth, E., Trowbridge, L., Teplitsky, S., Barnes, C., Fireman, E., Dorman, J., & Bellows, J. (2012). Factors contributing to all-cause 30-day readmissions: A structured case series across 18 hospitals. Medical Care, 50(7), 599–605. https://journals.lww.com/lwwmedicalcare/Abstract/2012/07000/Factors_Contributing_to_All_cause_30_day.7.aspx
Kurtz, S., Lau, E., Ong, K., Adler, E., Kolisek, F., & Manley, M. (2016). Which hospital and clinical factors drive 30- and 90-day readmission after total knee arthroplasty? The Journal of Arthroplasty, 31(10), 2099–2107. https://www.sciencedirect.com/science/article/pii/S0883540316300043
Phruetthiphat, O., Otero, J. E., Zampogna, B., Vasta, S., Gao, Y., & Callaghan, J. J. (2020). Predictors for readmission following primary total hip and total knee arthroplasty. Journal of Orthopaedic Surgery, 28(3). https://journals.sagepub.com/doi/10.1177/2309499020959160A