Clinical Practice Experience (CPE) task

For the purpose of this CPE, a Patient Care Transition Coordinator is defined as a nurse who focuses on assisting patients moving from the hospital to a rehabilitation facility, and then to their homes. During this experience, you will help specific patients move through different levels and types of care. You will identify the education, experience, and skills required for you to perform this role successfully. Additionally, as a Patient Care Transition Coordinator, you should aim to prevent hospitalization and re-hospitalization of patients who returned to their homes after hospitalization and rehabilitation.
The task is comprised of three phases of the transitions of healthcare continuum for a patient. You will examine and discuss evidence-based practices for a selected patient with one of the conditions or procedures identified by the CMS Hospital Re-admissions Reduction Program (HRRP). Patient scenarios for each of the conditions or procedures follow the instructions.

Transitions of care without readmission

The three phases on which you will focus are:

·      Transition from hospital to home or sub-acute care facility

o   Discuss the HRRP readmission reduction plan.

Research the CMS HRRP https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

·      Briefly discuss the elements and criteria used for the CMS HRRP conditions/procedures payment reduction plan for re-admissions within 30 days of discharge.

o   Provide introduction to your patient and discuss pre-discharge initiative/interventions to promote optimal recovery and prevent readmission within 30 days or less.

Interaction Between Nurse Informaticists and Other Specialists

Develop/propose a Care Transition Plan for the patient with the condition or procedure that you chose for your CPE.

o   Incorporate individual, social determinants, community, system-level, and condition/procedure specific considerations with emphasis on interventions and initiatives to prevent readmission within 30 days of discharge.

·      Reduction of all-cause, non-disease-specific re-admissions

o   Research and discuss evidence-based practices for effectively transitioning patient from facility to home with specific focus on preventing all-cause hospital re-admissions.

Research the evidence-based practices for effectively transitioning patients from the hospital (& rehabilitation unit) to home with the specific focus on preventing all-cause hospital readmission. Utilize your textbooks, online resources, and other sources as needed.

o   Incorporate social determinants of health considerations that impact all-cause re-admissions and how to prevent them with focused interventions or initiatives for your patient targeting the individual, community, and system levels.

·      Discuss evidence-based practices focused on preventing all-cause hospital re-admissions.

Incorporate individual, community, system, and social determinants of health considerations that impact all-cause readmission and how to prevent them.

·      Primary, secondary, and tertiary strategies to prevent hospitalization

o   Research and discuss approaches to impact/reduce hospitalization utilizing primary, secondary, and tertiary prevention initiatives focusing on the individual, community, and system level specific to your patient’s condition or procedure.

·      Based on research, create an extension of the HRRP that focuses on successfully preventing hospitalization through primary, secondary, and tertiary prevention methods.

Initiatives should incorporate individual, social, community, system-level, and condition/procedure specific considerations.

Patient Chosen

Pneumonia 

Lakshmi is a 73-year-old Indian female who is being discharged from the hospital after a 4.5-day inpatient stay for treatment of community acquired pneumonia (CAP). Lakshmi started feeling ill ten days ago, and thought that her cough, fever, and body aches were either a bad cold or maybe the flu. When her symptoms seemed to worsen and she started feeling short of breath, she went to a local urgent care for an examination. The provider in the urgent care collected her health information, conducted a physical examination (coarse breath sounds in the lower lobes), and performed a chest x-ray which showed right lower lobe pneumonia. Lakshmi’s blood pressure at the urgent care was 88/65, her BUN was 10, she was not confused, and her respiratory rate was 24. The provider explained the benefits of hospitalization versus in-home treatment, CURB-65 score, and recommendation for hospitalization. Lakshmi agreed with that plan, the provider called the local hospital to arrange for a direct admit, and Lakshmi’s husband drove her to the hospital.

While hospitalized, Lakshmi continued her normal medications and was also given intravenous antibiotics. Additionally, she was given 2L of oxygen by nasal cannula.  Lakshmi will be discharged home today, with plans to follow up with her primary care provider in the next two weeks.

Lakshmi’s other history is as follows (at discharge): Ht: 5’1”  WT: 123 lbs  BP: 106/68 Temp: 98.2 F  O2 sats: 98% on RA Pain: 0/10

Insurance: Medicare Advantage

PMH: Osteopenia, 2014. Fractured femur, motor vehicle accident, 1984. Migraine headaches.

FH: Father deceased, stroke at 68. Mother alive, 98, osteoporosis, hearing loss. Son, 47, alive and well.

SH: Lakshmi was born and raised in an affluent part of India and emigrated to the US to pursue her education. She has a bachelor’s degree in biology and a master’s degree in microbiology. She is a retired microbiologist. She is married with one child who lives several states away with his family. Husband is a retired financial analyst. They live in a downtown high-rise condominium next to a city park. There are several grocery stores within a 0.5 mile walk from their condo. Lakshmi and her husband often trade off cooking duties and eat traditional Indian cuisine at home. Lakshmi walks for exercise 5 days a week for 30-45 minutes. No smoking history. Does not drink alcohol. Drinks black tea two to three times a day, and no soda. Lakshmi and her husband attend the local Hindu temple for worship and meals, 1-2 times per week. She is also part of a neighborhood book club and travels nationally and internationally 2-3 times per year.

Meds: Vit-D 1000 U tab, 1 tab per day. Calcium carbonate 600 mg tab, 2 tabs daily. Levofloxacin 750 mg tab, 1 tab daily for 2 days. Excedrin Migraine 2 tabs by mouth every 24 hours as needed for migraine.

Allergies: NKDA, No food or environmental allergies.

Noah Caputo Dermatology School Age Sick Visit Shadow Health Care Plan

Clinical Practice Experience (CPE) task

Re-Iteration

For this CPE, we define a Patient Care Transition Coordinator as a nurse who helps patients move from the hospital to a rehabilitation facility and then to their homes. Your role involves assisting specific patients through different levels and types of care. To perform this role successfully, you need to identify the education, experience, and skills required. As a Patient Care Transition Coordinator, your goal is to prevent hospitalization and re-hospitalization of patients returning home after hospitalization and rehabilitation.

The task consists of three phases in the healthcare continuum for a patient. You will explore evidence-based practices for a selected patient with conditions or procedures identified by the CMS Hospital Re-admissions Reduction Program (HRRP). Patient scenarios for each condition or procedure follow the instructions.

Transitions of care without readmission

You will focus on three phases:

1. Transition from hospital to home or sub-acute care facility
– Discuss the HRRP readmission reduction plan.
Research the CMS HRRP https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

2. Briefly discuss elements and criteria for the CMS HRRP conditions/procedures payment reduction plan for readmissions within 30 days of discharge.
– Provide an introduction to your patient and discuss pre-discharge initiatives to promote optimal recovery and prevent readmission within 30 days.

3. Develop/propose a Care Transition Plan for the patient with pneumonia.
– Incorporate individual, social determinants, community, system-level, and condition-specific considerations with a focus on preventing readmission within 30 days of discharge.

Reduction of all-cause, non-disease-specific readmissions

4. Research and discuss evidence-based practices for effectively transitioning patients from facility to home, with a specific focus on preventing all-cause hospital readmissions.
– Incorporate social determinants of health considerations impacting all-cause readmissions and how to prevent them.

5. Discuss evidence-based practices focused on preventing all-cause hospital readmissions.
– Incorporate individual, community, system, and social determinants of health considerations that impact all-cause readmission and how to prevent them.

Primary, secondary, and tertiary strategies to prevent hospitalization

6. Research and discuss approaches to impact/reduce hospitalization using primary, secondary, and tertiary prevention initiatives specific to your patient’s condition.
– Create an extension of the HRRP that focuses on preventing hospitalization through primary, secondary, and tertiary prevention methods.

Patient Chosen: Pneumonia

Lakshmi, a 73-year-old Indian female, is being discharged after a 4.5-day inpatient stay for community-acquired pneumonia (CAP). She started feeling ill ten days ago and sought care when her symptoms worsened. Lakshmi’s medical history includes osteopenia, a fractured femur from a motor vehicle accident in 1984, and migraine headaches. She has Medicare Advantage insurance.

Lakshmi’s lifestyle involves regular exercise, no smoking or alcohol, and a traditional Indian diet. She and her husband attend the local Hindu temple, and she participates in a neighborhood book club. She travels nationally and internationally 2-3 times per year.

Her medications include Vitamin D, calcium carbonate, levofloxacin, and Excedrin Migraine. She has no known allergies.