WGU NURS 5205 D028 Advanced Health Assessment for Patients and Populations - Care Transition Plan

Medicare Hospital Readmission Reduction

The medical institution Readmissions Discount Software Program (HRRP) is a Medicare initiative designed to promote price-primarily based searching. This software program software program goals to beautify care coordination and case manipulation with the useful resource of way of regarding patients and caregivers in making plans and discharge tactics.

HRRP aligns with national efforts to decorate healthcare outstanding and accessibility through price-based total care models (Facilities for Medicare & Medicaid Services, n.d.).HRRP desires specific situations for readmission internal 30 days, collectively with acute myocardial infarction (AMI), chronic obstructive pulmonary sickness (COPD), coronary heart failure (HF), pneumonia, coronary artery skip thru graft (CABG) surgical remedy, and non-obligatory number one everyday hip and knee arthroplasties (THA/TKA).

To encourage higher outcomes, this device reduces payments for patients readmitted with the ones conditions within the 30-day window (facilities for Medicare & Medicaid Services, n.d.).Readmissions pose great worrying situations, which incorporate not on-time recuperation, multiplied fees, prolonged-term fitness implications, and dissatisfaction among patients and families. Common placed up-discharge headaches consist of joint dislocation, deep vein thrombosis (DVT), placed up-operative infections, and pulmonary embolism (PE).

Case Study Overview

The affected person, Susan, is a sixty-eight-twelve months-antique female who currently underwent non-obligatory popular left hip arthroplasty as a result of severe osteoarthritis causing large joint degeneration. Susan has a supportive domestic surrounding, living together with her husband and having a prolonged family close by who can help if desired. Her hospital stay used to be uneventful, with inpatient bodily treatment supporting her healing and ache control below management, making her prepared for discharge.

Key Considerations for Safe Discharge

To lower the risk of readmission, Susan needs to actively interact in her discharge design. This consists of the perception of her located up-operative care requirements, having enough domestic aid, and adhering to remedy and remedy regimens. The following factors are necessary.

1. home environment

Susan’s non-public home needs to accommodate her put-up-surgical goals. The vital device, along with a walker and a raised commode seat, must be available to prevent dislocation or damage.

2. Follow-Up Care

• Outpatient bodily therapy 2 instances weekly, grade by grade growing interest stages as advocated with the useful resource of the usage of the therapist and health care organization.
• Scheduled take a look at-America with the healthcare professional at two and 6 weeks placed up-surgical operation.
• Visits collectively together with her number one care physician (PCP) at four and 8 weeks for remedy reconciliation and ordinary evaluation.

3. Discharge Instructions

Specific suggestions need to include physical remedy sports activities sports, scheduled study-up appointments, and remedy manipulation. The nurse should affirm that prescriptions are accurate and offer clean commands, supplemented via written substances from the pharmacist.

4. Medication Management

the subsequent medicinal tablets are part of Susan’s discharge sketch

• Aspirin: 80 mg each day to save you from clot formation.
• Enoxaparin: forty mg subcutaneous injection each day for seven days to lessen DVT and PE risks.
• Ibuprofen: 2 hundred mg, 1-2 capsules each four hours as desired for pain.
• Acetaminophen: five hundred mg, 1-two drugs each 4-6 hours as wanted (maximum six tablets steady with day).
• Oxycodone: five mg, 1 tablet each 4-6 hours as preferred for immoderate pain.

Communication Channels

A reliable verbal exchange tool, inclusive of the healthcare professional’s on-call employer, must be in the region for Susan or her circle of relatives to address problems or seek recommendations without delay.

By addressing those elements, the care organization can facilitate a clean transition for Susan, assisting her recovery and minimizing the chance of readmission.

References

Centers for Medicare & Medicaid Services. (n.d.). Clinic Readmissions Good buy software program (HRRP). Retrieved from https://www.cms.gov/Medicare/Medicare-fee-for-carrier-rate/AcuteInpatientPPS/Readmissions-good buy-utility