Capella FPX 4005 Assessment 4

Capella FPX 4005 Assessment 4

Name

Capella University

NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations

Prof. Name

Date

Stakeholder Presentation

Hello, my name is ——, and I am here to present a critical initiative designed to address the elevated readmission rates at Cedar Valley Health Center, particularly among patients with diabetes and hypertension. These increasing rates indicate the urgent need for an interdisciplinary solution that reduces care fragmentation and strengthens transitional support across all patient populations. This proposal presents an evidence-based, collaborative approach aimed at enhancing care coordination, improving discharge planning, and promoting effective communication among healthcare teams. We strive to reduce avoidable readmissions, improve patient outcomes, and raise our facility’s overall quality of care.

Issue Identification

Cedar Valley Health Center’s challenge is the high rate of patient readmissions resulting from fragmented care, inadequate discharge planning, and poor coordination of care settings. The current strategies, isolated discharge instructions, and limited post-discharge follow-up have failed to address the problem. Therefore, patients encounter preventable complications and repeated hospital visits, which result in increased healthcare costs and poor patient satisfaction (Brown et al., 2021). This challenge is particularly critical to healthcare providers and administrators because care quality and organizational efficiency are undermined.

Relevance of the Issue

Hospital readmissions and better patient outcomes depend on effective care transitions and interdisciplinary coordination. Fragmented communication and the absence of structured follow-up result in care gaps and adverse events following discharge in studies (Ibrahim et al., 2022). Cedar Valley Health Center can enhance its reputation as a high-quality, patient-centered facility by implementing integrated care strategies and improving team collaboration to strengthen transitional care and reduce unnecessary readmissions.

Relevance of an Interdisciplinary Team Approach

Addressing High Readmission Rates

It is essential to reduce hospital readmissions among patients with diabetes and hypertension at Cedar Valley Health Center to enhance patient safety and overall quality of care. Among these patient groups, fragmented care transitions are particularly prone to deteriorating health and recurrent hospitalization due to inadequate discharge planning and insufficient follow-up protocols. This problem hinders patient well-being and adds to the burden and stress of healthcare personnel responsible for handling complex cases. A comprehensive interdisciplinary approach is implemented, with nurses, physicians, social workers, and care coordinators working together as a team, to ensure that patients receive comprehensive discharge planning and adequate post-discharge support. Collaboration is essential in addressing the complex needs of patients with diabetes and hypertension to preventable readmissions (Hayes et al., 2024).

Enhancing Transitional Care Through Collaborative Strategies

Improving transitional care for patients with diabetes and hypertension is dependent on adopting an interdisciplinary team model at Cedar Valley Health Center that is specifically tailored for this patient population. This approach brings together the expertise of many healthcare professionals, enabling thorough patient assessments, cohesive care planning, and tailored follow-up procedures to address the specific challenges associated with managing these chronic conditions (Hayes et al., 2024). Interprofessional rounds are conducted regularly and utilize Collaborative Care Models, which facilitate communication among all members of the interprofessional team and promote joint decision-making to ensure that all aspects of a patient’s health, including medication management and lifestyle modifications, are well-coordinated (Harrison et al., 2021). 

Failure to address the high readmission rates at Cedar Valley Health Center could lead to continued patient harm, increased healthcare costs, and penalties from value-based reimbursement programs. Fragmented care may lead to preventable complications, decreased patient satisfaction, and erosion of trust in the facility. Additionally, the organization risks staff burnout and inefficiencies due to repeated hospitalizations and poorly coordinated care. Over time, this could damage Cedar Valley’s reputation and ability to compete in a quality-driven healthcare landscape. A structured collaboration will optimize resource use and reinforce a culture of safety and accountability within the organization (Karam et al., 2021).

Interdisciplinary Plan Summary

Objective

The approach at Cedar Valley Health Center focuses on reducing elevated readmission rates by implementing a comprehensive, interdisciplinary transitional care strategy for patients with diabetes and hypertension, with a particular emphasis on readmission rates. Early discharge planning, coordinated care, and structured post-discharge support are emphasized for this initiative to ensure continuity of care and to prevent avoidable hospital readmissions.

Likelihood of Success  

This approach is likely to succeed, and strong evidence supports this. Karam et al. (2021) demonstrate that early discharge planning, interprofessional communication, and structured follow-up have a significant impact on patients’ outcomes and readmissions. Incorporating these evidence-based strategies into Cedar Valley’s care model, especially for high-risk patients, positions them well to achieve measurable improvements in patient satisfaction and clinical outcomes.

Actions 

Cedar Valley will plan a targeted transitional care protocol using the Plan-Do-Study-Act (PDSA) model. Patients identified as high risk, especially those with diabetes or hypertension, are discharged with a plan initiated upon admission by the nurse case manager. The plan will outline team roles: pharmacists will conduct medication reconciliation and education, social workers will assess social determinants of health and arrange post-discharge services, and attending physicians will make medical decisions. Clear communication and alignment of care team members will be maintained through daily interprofessional rounds and weekly case reviews. This plan will be piloted in the “Do” phase with a select patient group, and the social worker will follow up with the patient in 48 hours post-discharge to address immediate barriers.

During the “Study” phase, monthly readmission rates, medication adherence, and patient satisfaction will be reviewed, and staff feedback will be collected to assess the effectiveness of the strategy (McKenna et al., 2023). The final “Act” phase will involve using the collected data to refine the process further and expand the intervention throughout all units, institutionalizing interprofessional rounds and collaborative care models as a standard part of Cedar Valley’s patient care. By working in this manner, structuring and collaborating, Cedar Valley Health Center aims to establish a safer and more efficient care transition process that better serves patients and reduces unnecessary readmissions (McKenna et al., 2023).

Implementation and Resource Management

A carefully structured framework is necessary for an interdisciplinary plan to reduce hospital readmissions at Cedar Valley Health Center, especially for patients with chronic conditions, including diabetes and hypertension. The scope of the intervention will be defined first, including clearly assigned roles and responsibilities for each team member. Upon admission, a full-time nurse case manager will initiate discharge planning for high-risk patients. At the same time, a part-time social worker will coordinate social determinants of health and post-discharge support. Estimated to cost $60,000 and $35,000 a year, these staffing adjustments would allow the center to run with current staffing levels at a minimal financial outlay.

Medication reconciliation responsibilities will be integrated into the clinical pharmacist’s existing workflow, eliminating the risk of medication misunderstandings for patients. Daily interprofessional rounds will include structured discussion among nurses, physicians, pharmacists, and social workers. We estimate $5,000 to support this model, covering staff communication and care coordination training. While most technological infrastructure is in place at Cedar Valley, a small EHR system upgrade (approximately $10,000) will enhance real-time documentation and team communication, particularly during care transitions.

The estimated cost of staffing adjustments, training, and technological improvements is $110,000. Nevertheless, they are outweighed by the potential savings from reduced hospital readmissions. The national burden of readmission-related costs is $17.4 billion, and considering the national burden of $17.4 billion, Cedar Valley could recoup its investment by preventing as few as 10 readmissions annually (Agube, 2023). Care coordination programs, such as those in managed care, have reduced readmissions and improved patient outcomes and organizational efficiency (Fu et al., 2023). Cedar Valley can proactively address discharge planning and transitional care through a well-resourced, interdisciplinary model, thereby improving care quality, maintaining financial sustainability, and protecting the organization’s long-term reputation.

Evidence-Based Criteria for Evaluation

Evaluating the outcomes of the care coordination initiative at Cedar Valley Health Center can be done using evidence-based metrics such as reduced hospital readmission rates, improved care plan adherence, increased patient satisfaction, and enhanced interprofessional collaboration. A 25% reduction in 30-day readmissions among high-risk patients with diabetes and hypertension within six months of implementation would be a key success indicator, aligning with the outcomes of similar interventions in coordinated care models (Thyagaturu et al., 2021). Through standardized surveys, a 10% improvement in satisfaction scores regarding discharge planning and care continuity can be measured for patient satisfaction, as reported by Agube (2023).

Staff surveys and structured feedback will measure communication and collaboration, aiming to achieve at least 80% of team members reporting improved coordination and clarity during interdisciplinary rounds (Karam et al., 2021). EHR audits can track adherence to care plans (medication and follow-up visits) to increase adherence by 20% in the intervention group. In addition, monthly outcome monitoring will include rates of completing post-discharge follow-up within 48 hours, a minimum of 90%.

These metrics blend quantitative and qualitative evaluation methods. For instance, if readmissions go from 40 to 30 per quarter, that represents a 25% improvement. At the same time, patient and staff feedback will complement the numbers, helping pinpoint successes and further refine the program. Integrating these outcomes allows Cedar Valley to hold itself accountable, continually improve the quality of care and operational effectiveness, and measure the improvements.

Conclusion

A conclusion is drawn that the proposed interdisciplinary care coordination initiative at Cedar Valley Health Center offers a viable, evidence-based solution to reducing avoidable readmissions and improving patient outcomes. This approach strengthens transitional care for high-risk populations by improving communication, discharge planning, and post-discharge support. Resources are utilized strategically and continually evaluated for both clinical and operational benefits. Ultimately, this initiative is putting Cedar Valley at the forefront of providing high-quality, patient-centered care.

References

Agube, K. (2023). How provider education on identification and referral of eligible patients to a care management program affects readmission rates: An evidence-based project. https://digitalcommons.pvamu.edu/dnp-projects/1 

Brown, C. S., Montgomery, J. R., Neiman, P. U., Wakam, G. K., Tsai, T. C., Dimick, J. B., & Scott, J. W. (2021). Assessment of potentially preventable hospital readmissions after major surgery and association with public vs private health insurance and comorbidities. JAMA Network Open, 4(4), e215503. https://doi.org/10.1001/jamanetworkopen.2021.5503

Fu, B. Q., Zhong, C. C., Wong, C. H., Ho, F. F., Nilsen, P., Hung, C. T., … & Chung, V. C. (2023). Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies. International Journal of Health Policy and Management, 12, 7089.

Capella FPX 4005 Assessment 4

Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where do models for change management, improvement, and implementation meet? A systematic review of the applications of change management models in healthcare. Journal of Healthcare Leadership, 13(2), 85–108. https://doi.org/10.2147/JHL.S289176

Hayes, C., Manning, M., Fitzgerald, C., Condon, B., Griffin, A., O’Connor, M., Glynn, L., Robinson, K., & Galvin, R. (2024). Effectiveness of community‐based multidisciplinary integrated care for older adults with general practitioner involvement: A systematic review and meta‐analysis. Health & Social Care in the Community, 2024(1). https://doi.org/10.1155/2024/6437930

Ibrahim, H., Harhara, T., Athar, S., Nair, S. C., & Kamour, A. M. (2022). Multi-disciplinary discharge coordination team to overcome discharge barriers and address the risk of delayed discharges. Risk Management and Healthcare Policy, Volume 15(15), 141–149. https://doi.org/10.2147/rmhp.s347693

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1), 16. https://doi.org/10.5334/ijic.5518

Capella FPX 4005 Assessment 4

McKenna, A. L., Carter, L. E., Kase, A. M., McCain, J. D., Fitzgerald, P. J., Kesler, A. M., Varma, S., & J. Colt Cowdell. (2023). Closing the gap in direct admissions: A quality improvement project. Quality Management in Health Care, Publish Ahead of Print. https://doi.org/10.1097/qmh.0000000000000412

Thyagaturu, H. S., Bolton, A. R., Li, S., Kumar, A., Shah, K. R., & Katz, D. (2021). Effect of diabetes mellitus on 30 and 90-day readmissions of patients with heart failure. The American Journal of Cardiology, 155, 78–85. https://doi.org/10.1016/j.amjcard.2021.06.016