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 settings remain a persistent challenge that negatively affects patient outcomes. These outcomes may include malnutrition, cognitive decline, frequent falls, delayed rehabilitation, and in some cases, death. In the United States, over 16,000 skilled nursing facilities (SNFs) provide care to approximately 1.35 million individuals annually, delivering services ranging from skilled nursing and rehabilitation to support with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Centers for Medicare & Medicaid Services [CMS], 2019).

Although many patients transition into long-term care, a significant portion receives short-term rehabilitation before returning home, often with continued support through home health services. A major obstacle for these facilities is the high rate of hospital readmissions, which exposes patients to avoidable complications, worsens health outcomes, and delays their recovery and return to baseline functioning (CMS, 2019).

Some common issues leading to readmission after discharge to post-acute care facilities include:

Contributing Factors	Impact on Patient Outcomes
Cognitive impairments	Confusion, reduced self-care ability, safety risks
Sepsis	Life-threatening infection, prolonged recovery
Increased falls	Injuries, fractures, loss of independence
Feeding difficulties/decreased appetite	Malnutrition, delayed healing
Death	Fatal outcomes from preventable conditions

These issues highlight the urgent need for evidence-based strategies to prevent readmissions and safeguard patient well-being.

Practice Problem and Question

Data show that patients discharged to SNFs experience a 17.8% readmission rate, compared to 15.8% among those discharged home (UpToDate, 2019). With more than 35 million hospital discharges annually in the U.S., unplanned readmissions contribute an estimated $15–20 billion in healthcare costs each year (UpToDate, 2019).

While Medicare initiatives and penalties have driven improvements, readmission rates remain concerning. For example, between 2003 and 2007, nearly 20% of Medicare patients were readmitted within 30 days of discharge (UpToDate, 2019). These figures emphasize the urgent need to bridge the gap between research evidence and clinical practice.

As a Doctor of Nursing Practice (DNP) scholar, my responsibility lies in:

• Identifying gaps between evidence-based guidelines and clinical practice.
• Designing and implementing interventions that reduce preventable readmissions.
• Enhancing patients’ quality of life through improved post-acute care 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?

Current CMS guidelines recommend provider visits every 30 days or as medically necessary. By contrast, acute care settings ensure daily multidisciplinary rounds, enabling timely identification of complications. However, patients in SNFs often deteriorate rapidly under less frequent monitoring, leading to late detection of health decline and unnecessary hospital transfers (CMS, 2019).

Increasing provider rounds to several times per week may enhance early recognition of clinical changes, support timely interventions, and ultimately reduce preventable rehospitalizations.

Evidence Synthesis of Literature to Address the Selected Practice Problem

A literature review was conducted to examine strategies aimed at reducing hospital readmissions in post-acute care. Four key studies were identified:

Author/Year	Focus of Study	Key Findings	Implications for Practice
Hatipoğlu et al., 2018	Prediction of 30-day readmission in pneumonia patients	330/628 patients aged ≥65 were readmitted within 30 days. Better discharge planning and transition processes reduced readmissions.	Highlights the importance of individualized discharge planning and risk assessment tools.
March & Mennella, 2018	Quality improvement in long-term care	Poor staffing ratios and inadequate resources linked to higher readmissions.	Advocates for improved staffing, work environment, and education to enhance outcomes.
Dadosky et al., 2018	Telemanagement of heart failure patients	Telemonitoring reduced rehospitalizations by 29%, with an absolute risk reduction of 6.51%.	Telehealth is cost-effective long-term and supports early detection of complications.
Agarwal & Werner, 2018	Accountable Care Organizations (ACOs) and readmissions	Participation in ACOs led to a -1.7% readmission reduction, $940 lower Medicare costs, and 3.1 fewer hospital days.	Demonstrates financial and clinical benefits of value-based care models.

Summary of Evidence:
All four studies emphasize the importance of enhanced monitoring, improved staffing support, telehealth integration, and structured discharge planning. Collectively, these interventions reduce readmissions and improve patient outcomes in post-acute settings.

Appraisal of the Evidence

The selected studies were rated at Level III evidence (good strength/quality), with findings relevant and applicable to clinical practice. While limitations existed—such as small sample sizes and varying study designs—the evidence strongly suggests that multifaceted interventions (clinical rounding, telehealth, staffing improvements, and care coordination) can significantly decrease readmission rates.

Translation Path

Implementation of interventions in post-acute care requires addressing both internal and external barriers. Challenges include staffing shortages, financial restrictions, patient non-compliance, and limited regulatory flexibility. To address these, a multidisciplinary approach—involving providers, nurses, pharmacists, therapists, and social workers—is essential.

Application of Lewin’s Change Model:

Stage	Action Steps
Unfreezing	Identify the need for change, engage stakeholders, build awareness of high readmission costs and poor outcomes.
Changing (Moving)	Implement frequent provider rounds (2–3 times weekly), strengthen nurse education, and encourage team-based huddles.
Refreezing	Sustain changes through policy updates, continuous monitoring, and reinforcing the new culture of proactive care.

Anticipated Outcomes:

• Reduced readmission rates.
• Improved patient safety and functional recovery.
• Better care coordination among interdisciplinary teams.
• Enhanced sustainability of evidence-based practices.

Conclusion

Post-acute care facilities are vital in supporting patient recovery after hospitalization, yet frequent readmissions undermine patient safety and increase healthcare costs. Evidence indicates that more frequent provider rounding, enhanced staffing support, telehealth integration, and value-based care models are effective in reducing rehospitalizations.

As a DNP-prepared nurse, my role is to champion these evidence-based interventions, collaborate with interdisciplinary teams, and ensure their sustainable integration into practice. Ultimately, these efforts will lead to improved patient outcomes, reduced healthcare costs, and higher quality of care in post-acute care 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

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

NR 706 Week 4 Information Systems Translation Science Project Guidelines.

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

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

NR 706 Week 4 Information Systems Translation Science Project Guidelines.

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

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