Interdisciplinary Plan Proposal
In this article, there is a description of an interdisciplinary proposal with a plan regarding using a 7-day post discharge transition protocol program. The plan of the program will take place in Pity County Hospital and in the community forming part of the county. Following its implementation, it is intended to reduce the readmission rates experienced by the hospital’s ED department and improve the facility’s goals of improved patient outcomes and gaining optimum reimbursement rates.
Objective
To inculcate a 7-day post-discharge transition protocol program into the post-discharge programs of the hospital with organizational and community stakeholders to reduce the readmission rates to Pity County Hospital. This objective is aligned to the broader corporate goal of improving the overall patient outcomes and patient satisfaction, and improving its post-discharge reimbursement rates, if successful, should improve outcomes by reducing the number of visits to the ED department after discharge.
Questions and Predictions
- How much of the workload will the use of the post-discharge transition program add to the outpatient clinicians’ workload? In the initial stages following the implementation of the program, it will increase their workload at an estimated percentage of 15%. Nonetheless, progressively when the discharged patients adhere to the discharge protocols, the visits to the outpatient clinics for review on adherence, will reduce.
- What guideline or policy will apply in circumstances where the discharged patient fails to adhere to the 7-day return to the outpatient department of the facility? The nurses deployed in the community will collaborate with the volunteer community health workers and community leaders to trace such patients’ whereabouts and conducting follow-ups.
- What will be the source of funding for the education program and follow-up for patients, their families, or caregivers concerning adherence to the post-discharge guidelines and the 7-day return to the facility? As the management, we will involve the County Assembly in increasing the allocation fund by 10% to healthcare in their budget through a lobbying process, thus acquire adequate funds for the education and follow-up program.
Change Theories and Leadership Strategies
Research evidence indicates that using local and community approaches in post-discharge programs are crucial in reducing patient readmission rates (Warchol, Monestime, Mayer & Chien, 2019). In effect, the successful implementation of the interdisciplinary plan, the Planned Change, and the Kurt Lewin change theories will get utilized. In the seven-step Planned Theory of Change, being a change agent, I would collaborate with Matt and the leadership management team of the hospital for effective change. With the pre-existing motivation and desire from the healthcare providers in embracing change to reduce hospital readmission rates, it provides an opportunity to implement a well-designed post-discharge protocol. The program includes patient education, a 7-day return to the outpatient client for assessment of adherence, and conducting a community follow-up. Then, lobbying for funds from the county government for financial resources, and the deployment of community health nurses and volunteer community health workers for education and follow-up will follow. The patient would undergo education sessions before discharge, and in the long run, the desired change objective will get met by ensuring the program becomes part of the organization’s culture.
Kurt Lewin’s Theory of Change will guide in changing the existing culture and practice to the desired outcome of adopting a well-defined post-discharge program in reducing hospital readmissions. In the Unfreezing stage, the interprofessional team will collaborate and direct their efforts towards abolishing the conventional process of discharge that only included patient education without follow-up on their adherence and be ready to change it. After the team embraces the idea/ vision, the dynamic process of change will get implemented to effect the transition. A series of patient education would get provided before and after discharge by clinicians and community health care workers, respectively. Again, during this phase, patients will be required to return to the facility’s outpatient department clinics, 7-days after discharge, to assess their attitudes and level of adherence towards the education and practices advised earlier by outpatient clinicians. Facility professionals will collaborate with those at the community to monitor their adherence levels, provide education, contact -tracing, through follow-up visits. In the freezing stage, the management and all the stakeholders involved will collaborate to make the program become part of the organization’s culture after it meets the change objective even as more changes would follow (Udod, & Wagner, 2018).
Team Collaboration Strategy
I will identify all stakeholders for the new program and hold a meeting starting with the chief executive officer and the hospital leadership management team, the outpatient clinicians, the inpatient clinicians, community health workers, patients, and their kin, and community leaders. The proposed desired change is shared to them guided by the hospital’s shared vision and goals, and suggestions made for changes. A committee will get formed to communicate the plan to the County Health Officer so that a lobbying process for funding kickstarts in the County assembly. The committee will also get involved in identifying and deploying community health nurses and health workers who will collaborate with the hospitals clinicians in providing feedback on individual patient adherence levels to the post-discharge protocol. The inpatient nurses will work with other healthcare workers in providing patient education before discharge and submitting patient records to the outpatient clinicians after returning for the 7-day post-discharge review.
A leadership strategy utilized in this change process will be sharing a clear vision to guide interdisciplinary team collaboration (Pearson, 2020). The approach facilitates working towards meeting the organization’s goal of improving its reimbursement rates and improving the health outcomes of discharged patients. The vision revolving around embracing a well-designed post-discharge protocol will enable interdisciplinary teams to understand the need for change, get inspired, and motivated in collaborating to implement the program. As a leader, I will involve effective communication, relationship building approaches, leading change, and deliver patient care delivery models, for successful transition (Waxman, Roussel, Herrin-Griffith & D’Alfonso, 2017).
Required Organizational Resources
Additional finances of about $650 to pay each of the intended 50 recruited community health nurses and $300 for 70 the community health workers are required monthly. Also, an additional amount of $ 4000 is required monthly for each of the other four staff clinician members in the outpatient department. Such a measure is critical to reducing workload caused by the expected upsurge of visits contributed by the discharged patients. Fueling budget is estimated at $500 to enable the clinicians and community healthcare workers to conduct patient follow-ups and providing essential education within the community. The funds will get obtained through a lobbying process presented to the County Health Officer in the County assembly to increase Pity Hospital funding in the subsequent months to meet the costs. The total estimated required value of the project implementation in a month will total to $58100. If the plan is not undertaken and becomes unsuccessful, Pity County Hospital will continue incurring revenue losses of over $360000 annually through reimbursement penalties by Centers for Medicare and Medicaid Services (CMS).
References
Pearson, M. M. (2020). Transformational Leadership Principles and Tactics for the Nurse Executive to Shift Nursing Culture. JONA: The Journal of Nursing Administration, 50(3), 142-151.
Udod, S., & Wagner, J. (2018). Common Change Theories and Application to Different Nursing Situations. Leadership and Influencing Change in Nursing.
Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W. W. (2019). Strategies to Reduce Hospital Readmission Rates in a Non-Medicaid-Expansion State. Perspectives in health information management, 16(Summer).
Waxman, K. T., Roussel, L., Herrin-Griffith, D., & D’Alfonso, J. (2017). The AONE nurse executive competencies: 12 years later. Nurse Leader, 15(2), 120-126.