Introduction
The American healthcare system has undergone a transformation in recent years. Numerous structures and programs have been developed to increase access to care and facilitate the delivery of quality services. The aforementioned initiatives notwithstanding, the rate of hospital readmissions among individuals with chronic diseases remains relatively high. As a result, health institutions and affected patients must endure high costs and suffer the effects of increased morbidity and mortality. There is a need to address the highlighted health problem by educating patients on the measures they can take to ensure that they do not return to the hospital for admission soon after they are discharged. The promotion of health literacy among patients diagnosed with chronic illness is an effective means of reducing the frequency of hospital readmissions.
Proposed Intervention
The proposed intervention is a teaching plan to prevent readmissions among ethnically diverse patients to hospitals for chronic conditions. The plan involves the assessment of patient learning needs, the assessment of barriers to learning, and the identification of relevant topics. The areas that the plan addresses include disease pathogenesis and management, follow-up opportunities, community resources, and health-promoting activities that reduce the incidence of hospital readmissions.
Analysis of Intervention
Summary of the Population Problem
The Western world is experiencing an increase in chronic conditions due to a rise in the aging population as well as improved treatment options. The high cost of hospitalization increases the economic burden on ethnically diverse populations (Brunner-La Rocca et al., 2020). It is worth noting that chronic diseases seldom occur in isolation. A majority of affected individuals have other underlying conditions. A readmission is defined as repeat health institution admission for any cause within 30 days of discharge (Weiss & Jiang, 2021). In 2018, a total of 3.8 million adult readmissions were recorded representing a 14% readmission rate at an average cost of 15, 200 dollars (Weiss & Jiang, 2021). Of the chronic diseases evaluated, sickle cell trait and anemia had the highest overall readmission rate at 36.1%, and heart failure was among the top five causes of readmission in the American healthcare system (Weiss & Jiang, 2021). A return to the hospital is costly and increases the risk of mortality and morbidity.
Adolescents and young adults are adversely affected by complex chronic diseases. Evidence indicates that age is a significant risk factor for unplanned readmissions in the aforementioned age group (Dunbar et al., 2019). It is worth noting that a majority of patients with chronic diseases have significant mental health issues, which increase the complexity of managing their illness. The co-occurrence of depression has been shown to worsen the chronic illness and limit the affected individual’s ability to adhere to recommended treatment plans (Dunbar et al., 2019). Initiatives that are designed to address chronic illnesses must consider the mental well-being of the individuals in the target population.
Reasons for Selection
Readmissions are a serious burden to healthcare systems and patients in view of the fact that they result in increased morbidity and mortality. Healthcare costs and demand for services have skyrocketed in recent years (Taylor & Davidson, 2021). There is a need to reduce the burden financial burden associated with hospital readmissions on patients and healthcare systems. The teaching intervention was selected because it is an effective means of leveraging forward-thinking quality frameworks that facilitate the provision of quality services without disenfranchising healthcare personnel. In addition, it is a quality measure that reflects a commitment to deep patient values as well as their desire for good health. Finally, the intervention is a demonstration of the value of nursing care with measurable outcomes.
Relevance to Practice
There is an overwhelming abundance of information available to patients through a variety of media sources. As a result, many patients with chronic illnesses are often confused by conflicting messages. The teaching intervention is relevant to practice because it helps guide patients by providing accurate and evidence-based information. In addition, the active involvement of patients in the management of their illnesses facilitates the formation of strong therapeutic alliances, which increase the frequency of desirable outcomes.
Analysis
The implantation of the teaching intervention is hinged on change management, which is the process through which a professional supports others through an adjustment, with the intention of ensuring that success is achieved. Leadership is essential for the implementation of novel ideas that are intended to enhance the delivery of quality services. Nurse leaders must recognize the need for change and spearhead programs aimed at improving service delivery. In addition, it is essential to apply effective monitoring and assessment tools to ensure that the proposed interventions achieve the desired results. Leaders must also train and educate team members on the processes required for successful implementation while engaging all the relevant stakeholders. Finally, the project’s process must be analyzed and relevant alterations made to guarantee the achievement of set objectives.
Communication is integral to the patient care process. Avoidable re-admissions can be prevented if healthcare interventions such as the one proposed herein enhance a patient’s ability to understand their diagnosis, the nature of the treatment, and discharge instructions. The communication strategies that are essential in this context are active listening to grasp the exact nature of a patient’s complaints, observation of non-verbal cues to gain a holistic understanding of the patient’s condition, and the use of translators in instances where a language barrier exists. The teaching plan incorporates the aforementioned approaches to effectively address all patient concerns.
There are numerous benefits of gathering input from the program participants. Frequent readmissions can be addressed by building meaningful partnerships with the community. Such relationships foster the provision of feedback, which is essential in ensuring the seamless transition of patients into the community. The teaching plan aims to educate patients on the mechanisms in place to ensure the continuity of care. Community partners are able to address non-medical issues that increase the frequency of readmissions among patients with chronic illnesses. It is also worth noting that cooperation with community partners is essential for effective care coordination. The sharing of information with all parties involved in the patient’s care will ensure that services are delivered effectively and emergent needs are addressed in good time. Input from the community is essential in order to gain a comprehensive understanding of the cultural, literacy, and behavioral issues that can contribute to increased re-admissions.
The intervention will improve the quality of care by improving health literacy. A significant number of communities that experience increased re-admissions are characterized by chronic disease patients with limited knowledge of their health condition (Weiss & Jiang, 2021). In addition, these patients are unable to manage their medications, engage in appropriate self-care, and are often non-adherent to prescribed treatment plans. This intervention aims to screen and document the levels of literacy in the target community and provide health providers at every stage of care with a comprehensive summary of the findings. The provision of educational materials that incorporate adult learning principles is intended to enhance the patient’s understanding of their diagnosis and treatment options. The intervention is designed to alleviate the complexity of self-care management instructions to enhance compliance. Finally, the application of easy-to-understand terminology is intended to help patients understand their illnesses and all the associated complications. The aforementioned measures have the capacity to enhance patient education, thus reducing the frequency of re-admissions.
The teaching plan incorporates various community resources that are available for patients with chronic illnesses. The intervention guides patients on how to access medication assistance programs and daily living assistance initiatives. In addition, the program participants are guided on how they can access services linked to social determinants of health. These include food, housing, transportation, and employment services that are created to alleviate financial barriers that may impede the observance of recommended health behaviors. The teaching plan also provides information on how underinsured and uninsured individuals can access healthcare services. The aforementioned resources are vital for the maintenance of health, which is critical to preventing re-admissions.
Technology plays a critical role in the prevention of re-admissions. The teaching intervention employs visual aids and images that are projected onto a screen to help participants understand the issues being addressed. In addition, remote-access options are available for individuals that are incapable of reaching the designated teaching area. The use of telehealth facilities to teach patients the important aspects of their illnesses increases the program’s reach and ensures that a high number of individuals with chronic illnesses gain access to the information they require.
There are specific ethical elements that the teaching intervention observes. First, patient confidentiality, which is the health practitioner’s responsibility to keep all protected health information private, is observed (Open Resources for Nursing, 2022). All the data collected during the intervention’s implementation is protected from unauthorized access in a secure system. In addition, none of the patient’s medical records are shared with unauthorized individuals. The state board nursing practice standards that guided program development include the provision of respect for each of the participant’s inherent dignity and unique attributes (Open Resources for Nursing, 2022). In addition, there is a primary commitment to the patients and their health needs, as evidenced by the promotion and advocacy of patient rights, safety, and health.
Conclusion
The high rate of hospital readmissions is a matter that requires urgent attention. The adverse financial and health impacts necessitate the implementation of a health initiative designed to enhance patient literacy. Increased knowledge of disease processes, management alternatives, and available community resources improves the patient’s ability to adopt recommended health behaviors, thus reducing the frequency of readmission. The proposed intervention adheres to nursing ethical standards, prioritizes effective communication, and leverages technology to enhance efficiency. It is worth noting that state board nursing practice standards played a critical role in informing the intervention’s development and implementation. The teaching plan improves the quality of service delivery by improving health literacy, enhancing adherence to recommended treatment interventions, and encouraging the adoption of appropriate health behaviors. The reduction of hospital readmissions is a marker of improved health outcomes among individuals diagnosed with chronic illnesses.
References
Brunner-La Rocca, H. P., Peden, C. J., Soong, J., Holman, P. A., Bogdanovskaya, M., & Barclay, L. (2020). Reasons for readmission after hospital discharge in patients with chronic diseases- Information from an international dataset. PLoS ONE, 15, 1–19. Web.
Dunbar, P., Hall, M., Gay, J. C., Hoover, C., Markham, J. L., Bettenhausen, J. L., Perrin, J. M., Kuhlthau, K. A., Crossman, M., Garrity, B., & Berry, J. G. (2019). Hospital readmission of adolescents and young adults with complex chronic disease. JAMA Network Open, 2(7), 1–13. Web.
Open Resources for Nursing. (2022). Nursing fundamentals: Regulations & standards. Wisconsin Technical College. Web.
Taylor, K., & Davidson, P. M. (2021). Readmission to the hospital: Common, complex and time for a re-think. Journal of Clinical Nursing, 30(17–18), e56–e59.
Weiss, A. J., & Jiang, H. J. (2021). Overview of clinical conditions with frequent and costly hospital readmissions by payer, 2018: Statistical brief #278. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs, 3, 1–19. Web.