Name
Chamberlain University
NR-706: Healthcare Informatics & Information Systems
Prof. Name
Datea
Does frequent rounding and close monitoring of newly admitted patients in post-acute care settings, compared to current guideline recommendations, decrease hospital readmission rates over an 8-week period?
The PICOT framework is a structured approach for formulating clinical inquiries and guiding evidence-based interventions. It allows healthcare professionals to define the problem clearly and develop strategies that can be evaluated systematically.
| Element | Description |
|---|---|
| P (Population) | Older adults admitted to post-acute care facilities |
| I (Intervention) | Frequent rounding and comprehensive clinician assessments |
| C (Comparison) | Adherence to current practice guidelines |
| O (Outcome) | Reduction in hospital readmission rates |
| T (Timeframe) | 8-week period following admission |
This framework supports clinicians in examining whether enhanced monitoring and early interventions can reduce unnecessary rehospitalizations.
Hospital readmissions remain a major concern in post-acute care, posing both financial and clinical challenges. Rehospitalizations are estimated to cost approximately $40 billion annually, and research suggests that between 5% and 79% of these readmissions are preventable (Harris et al., 2018). Even a 10% reduction in rehospitalizations could save over $1 billion annually.
Beyond the economic impact, patients who experience frequent readmissions face extended recovery times, higher infection risks, and reduced independence. These outcomes often lead to functional decline, emotional distress, and a diminished quality of life, which underscores the need for proactive measures to prevent rehospitalization (Harris et al., 2018).
Does frequent rounding and oversight by clinicians reduce hospital readmission rates compared to current practice guidelines over an 8-week period for patients recently discharged to post-acute care?
Conducting comprehensive assessments and frequent follow-ups by clinicians and nursing staff.
Early detection of complications through closer observation.
Comparing frequent rounding against existing guideline-based care models.
Tracking readmission rates within an 8-week period to measure effectiveness (March & Mennella, 2018).
To ensure quality outcomes, the Centers for Medicare & Medicaid Services (CMS, 2019) introduced standardized measures to assess rehospitalizations following discharge.
| Measure | Key Focus |
|---|---|
| Unplanned rehospitalization (31 days) | Identifies unnecessary readmissions within a month of discharge. |
| Medical necessity vs. 30-day rounding | Evaluates adequacy of monthly rounding compared to frequent monitoring. |
| National average rehospitalization (27%) | Provides a benchmark for assessing facility performance. |
| Patient-centered care | Encourages individualized and holistic treatment approaches. |
| Insurance coverage inclusion | Promotes equity by ensuring all patient groups have access to appropriate care. |
These measures balance cost-effectiveness with patient safety and emphasize the importance of reducing preventable readmissions.
The Hospital Readmission Reduction Program (HRRP) highlights six key conditions for which 30-day readmission rates are measured to standardize risk and improve outcomes (Hatipoğlu et al., 2018):
Acute Myocardial Infarction (AMI)
Congestive Heart Failure (CHF)
Pneumonia
Coronary Artery Bypass Graft (CABG)
Chronic Obstructive Pulmonary Disease (COPD)
Elective total hip or knee arthroplasty
By linking financial incentives to performance on these conditions, HRRP promotes accountability and motivates facilities to adopt evidence-based strategies that prevent unnecessary hospital returns.
Addressing post-acute care rehospitalizations requires a patient-centered and collaborative care model. Key components include:
Shared decision-making between patients and clinicians, grounded in evidence-based care.
Allowing state and local flexibility to design innovative care delivery systems.
Implementing solutions that improve affordability, accessibility, and quality.
Prioritizing preventive care and early interventions to avoid costly complications.
FMEA is a proactive tool used to identify potential risks that could contribute to hospital readmissions.
| Failure Mode | Failure Cause | Potential Effect |
|---|---|---|
| Missed handoff reports | Incomplete communication between providers | Delayed treatment and missed interventions |
| Delayed assessment post-admission | Lack of awareness of new admissions | Increased risk of rehospitalization |
| Low rounding frequency | Late recognition of complications | Higher likelihood of readmissions |
This analysis highlights the importance of effective communication, timely assessments, and consistent rounding practices (Harris et al., 2018).
Multiple contributors influence high readmission rates in post-acute care (LUCA, 2016; March & Mennella, 2018):
Medical doctors and ARNPs: Variation in follow-up frequency and continuity of care.
Skilled nursing facilities: Inconsistent rounding and monitoring practices.
Electronic Medical Records (EMR) systems: Errors or inefficiencies in platforms such as PointClickCare and Gherimed leading to missed care opportunities.
Monitoring gaps: Delayed recognition of patient deterioration due to inadequate assessment practices.
These factors reveal that system-level improvements are just as critical as individual clinician performance in reducing readmissions.
Frequent rounding and close monitoring in post-acute care facilities offer substantial benefits, including:
Earlier detection of clinical deterioration.
Timely interventions that prevent complications.
Reduction in avoidable hospital readmissions.
Enhanced quality of life and functional outcomes for patients.
Decreased healthcare costs through efficient resource utilization.
Evidence strongly supports that proactive monitoring strategies not only improve patient safety and outcomes but also promote a sustainable, cost-effective healthcare model (UpToDate, 2019; Agarwal & Werner, 2018).
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
Center for Medicare & Medicaid Services. (2019). Skilled Nursing Facility 30-Day Potential Preventable Readmission Measure (SNFPPR). https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2801
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/s12913-018-2977-3
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
LUCA, L. (2016). A study on quality analysis measuring process. Fiability & Durability, 2, 68–72.
March, P. P., & Mennella, H. D. A.-B. (2018). Quality improvement in long-term care. CINAHL Nursing Guide.
UpToDate. (2019). Hospital discharge and readmission. https://www.uptodate.com/contents/hospital-discharge-and-readmission
