Author(s): Casey Walthall, DNP, MSN, RN
Director of Risk Management & Accreditation
Chamberlain University

Competency Domain: Performance & Process Improvement

Description: Acute care hospital readmission rates are used by accrediting agencies, regulatory entities, and major insurance companies to assess a healthcare company's performance of quality patient care. This project addressed the need to improve the quality of care provided to patients admitted to home health services by structuring the plan of care providing intermittent visits for ongoing support in the home to geriatric patients discharged from an acute care facility with ordered home health services. Problem:Decrease 30-day hospital readmission rates of home health patients. Measurement:EMR & SHP analytical software systems tracking transfer in facilities.Analysis:Comparison of pre & post data for percentage, chai squared statistical analysis - verified by a professional statistician. Implementation:The project intervention is nurse-led personalized care plans utilizing a modified structured 11-step process (clinical decision tool), established at the first home health visit. This project can be applied through the knowledge to action framework with a printed list to attach to clinicians' badge for reference. Results/DiscussionThe project intervention decreased hospitalization readmission rates by more than half of the pre implementation rate. The tool critical to the success was education prior to implementation & a badge list for clinician reference. Sustainability of the project includes companywide training & 'badge tags' with QA follow up.