Capstone Task 1

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Western Governors University *

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D226

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Apr 3, 2024

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Comprehensive Healthcare Change Proposal Andrew Buck Western Governors University D226: BSNU Capstone Debra Masterson March 23, 2024

A1. Innovative Change Introducing a specialized nursing position for high-risk geriatric patients aged 65 and above is highly recommended to cater to their specific needs and ensure optimal care. This dedicated nurse would closely monitor and attentively assess patients throughout their hospital stay, ensuring comprehensive and individualized support. Additionally, the nurse would extend their commitment to patient well-being beyond the hospital walls by providing invaluable assistance for a duration of 14 days post-discharge. One of the primary objectives of this specialized nurse would be to identify and address the social determinants of health that significantly impact geriatric patients. By thoroughly understanding the unique social circumstances, living conditions, and support systems available, the nurse would be able to effectively connect patients with the necessary community resources. This seamless integration of healthcare and community resources can greatly contribute to improving the overall health outcomes and quality of life for elderly patients. Furthermore, this specialized nurse would take on the role of an educator - equipping patients with vital knowledge on how to effectively manage chronic health conditions. Through comprehensive education, patients would become more empowered to actively participate in their own care, leading to better health outcomes. By teaching advocacy skills, the nurse would also empower patients to confidently navigate the complex healthcare system, ensuring they receive the best possible care and support. Overall, the introduction of this specialized nursing position would significantly enhance the level of care provided to high-risk, geriatric patients. The nurse's unwavering support, guidance, and resources would enable patients to effectively manage their healthcare needs outside of the hospital setting, thus drastically reducing the risk of unnecessary readmissions. The positive impact of this specialized nursing

position would be far-reaching, ultimately improving the quality of life and overall well-being of geriatric patients. A1a. Authorized Proposed Change See attached verification form. A1b. Organizational Sponsor Discussion I discussed my proposal with my ICU nurse leader, Donna Dally, who expressed great interest in the idea. I began our conversation by describing in detail the significance of the geriatric discharge nurse role and how it could greatly contribute to lowering our readmission rate while offering additional support to our geriatric patients. Donna attentively listened to my points and asked insightful questions, showing her dedication to thoroughly understanding the proposal. As we delved deeper into the discussion, we focused on the necessary steps that would be required to get the role approved. We explored various avenues, such as presenting the proposal to our hospital's administration, engaging with other department heads, and conducting research to gather supporting evidence. Donna shared her valuable expertise in navigating the bureaucratic processes within our healthcare system, providing guidance on whom to approach and the potential challenges we might face along the way. Moreover, we spent considerable time brainstorming the measures we would employ to assess the success of the proposed role. We recognized the importance of collecting accurate data and utilizing appropriate evaluation tools to measure the impact of the geriatric discharge nurse on readmission rates and patient satisfaction. Donna suggested involving our hospital's research department to ensure the validity and reliability of our assessments, thus ensuring that our findings would be credible and influential in making decisions regarding the role's future implementation.

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Overall, our discussion was fruitful and left both of us feeling optimistic and motivated. Donna applauded my initiative and encouraged me to proceed with the proposal. She kindly offered her ongoing support and pledged to assist in any way possible to bring the vision of the geriatric discharge nurse role to fruition. Our conversation served as a testament to the collaborative and forward-thinking nature of our healthcare team, where the ideas and concerns of all team members are not only heard but actively sought out. Together, we embarked on a journey that aimed to enhance the quality of care delivered to our elderly patients while simultaneously reducing the burden on our healthcare system. The proposed geriatric discharge nurse role represented a significant step towards achieving these goals, and with the support of Donna and our dedicated team, I felt confident that we were on the right path to success. A1c. Proposed Changes Since Donna's role as a highly experienced nurse leader affords her an extensive understanding of policy and procedure, we came to a collective decision to implement some modifications to the various phases. As a result, we have allocated a substantial 4-month period for the crucial "planning stage" of the GDN, ensuring that all necessary approvals and developments are thoroughly undertaken. Donna expressed her belief that incorporating the new and specific responsibilities of the GDN into the existing discharge nurse role would require a slightly longer timeframe than the initially estimated 2 months. Moreover, she highlighted the importance of dividing each phase into 4-month segments, as it would greatly assist us in later reviewing the timeline of our proposal. This strategic approach would enable us to seamlessly conduct a comprehensive quarterly end-of-year review exactly 12 months after the successful implementation. Further building on our collaborative efforts, we agreed to include a comprehensive patient survey as a pivotal measure of success. While we are fully aligned in our objective of achieving a noticeable decrease in readmission rates, we also strongly emphasized the significance of obtaining direct feedback

from patients regarding GDN’s impact on their overall healthcare journey. This invaluable information will undoubtedly aid us in refining and enhancing the role of the GDN, ensuring that it effectively caters to the diverse needs of patients during their hospital stay and even beyond. We firmly believe that such patient-centered feedback will play a pivotal role in the continuous growth and optimization of the GDN's role, ultimately resulting in the provision of the most beneficial healthcare experience for each patient we have the privilege to serve. A2. Data to Support the need for change. “ A remarkable demographic shift is anticipated to take place by the year 2030.” (Jonathan Vespa, David M. Armstrong, and Lauren Medina, 2020) This transformative change will witness a significant transformation wherein the number of individuals aged 65 and above will surpass the number of those aged 5 and below. Undoubtedly, this imminent phenomenon poses an unprecedented challenge to the healthcare industry, which is currently ill-equipped to effectively cater to the diverse and complex demands of an aging population. Recognizing the pressing need for innovation, this article puts forth a compelling proposition that for healthcare agencies to confront this burgeoning challenge head-on, it is imperative to implement novel and enhanced methods of care across local, state, and national levels. By diligently addressing these crucial priorities in a proactive manner, a robust and adaptable infrastructure can be established, one that fosters superior health outcomes and facilitates equitable, goal-directed care in full accordance with the distinctive preferences and requirements of older adults. This forward-thinking and comprehensive approach ensures that every facet of the geriatric population's healthcare needs is diligently catered to, thereby creating an environment conducive to their overall well-being. Furthermore, taking into account the gravity of this situation, I, as the proposer, am keen to concentrate my efforts on developing an innovative solution tailored to the unique needs of this aging population, specifically on the local level. This proposal not only aims to address the immediate

concerns of the elderly within the local community but also strives to serve as a pioneering prototype for other healthcare facilities throughout the state. If this proposal successfully delivers patient-centered care while substantially reducing rehospitalization rates, it has the potential to revolutionize the approach to geriatric healthcare and become an exemplary model for the entire state. In conclusion, it is abundantly clear that the age-old mechanisms and conventional practices employed within the healthcare industry are inadequate in meeting the emerging challenges posed by an aging population. By embracing the proposed paradigm shift in care and diligently implementing innovative strategies, we can pave the way towards a brighter future where the healthcare needs of older adults are met with unwavering dedication and compassion. Let us embark on this transformative journey together and forge a path that ensures the well-being and happiness of our cherished elderly population. A3. Change Barriers When implementing change, there will always be barriers to overcome. The first barrier I foresee would be the added cost to the organization to create a new nursing role. Adding the role of the GDN would mean allotting more of the organization’s money to fund this role. Therefore, we would need to carefully evaluate and reallocate financial resources to ensure the sustainable implementation of this new nursing position. This might involve analyzing current budget expenditures, identifying potential areas where funds can be redirected, and exploring opportunities for external funding or grant opportunities aimed at supporting innovative healthcare roles. The second barrier I foresee would be gaining support from other community resources for whom we would need to partner with in order to provide well-rounded, holistic patient care. Collaboration and cooperation with external organizations, such as local clinics, community centers, and social service agencies, would be crucial in establishing a network of care that addresses diverse patient needs.

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Building strong relationships with these community resources would involve actively seeking partnerships, engaging in ongoing communication and collaboration, and exploring mutually beneficial opportunities for knowledge sharing and skills development. Ultimately, by leveraging the expertise and resources of other community entities, we can enhance the quality and comprehensiveness of patient care, promoting better health outcomes for the individuals we serve. A4. Potential Negative Outcome A potential negative outcome of not implementing the proposal is that of an increasingly higher readmission rate as our geriatric population continues to age. This will create a heavier burden on our healthcare systems which are already struggling to provide the care required for an aging society. Furthermore, with the lack of implementation, we may also see a decline in the overall health of our elderly population, as they may not have access to the necessary interventions and treatments that the proposal could provide. Ultimately, the consequences of not acting could result in a significant strain on our healthcare resources, hinder quality of life for our senior citizens, and potentially exacerbate the existing healthcare disparities that affect the elderly. It is crucial that we address this issue, as failure to do so will have far-reaching implications for both our healthcare system and the overall well-being of our aging population. A4a. Potential Action Education on the importance of the Global Development Network's (GDN) role would undoubtedly be the most effective and impactful tool in helping my esteemed organization's administration comprehend and internalize the dire necessity of this exceptional service. As a responsible and diligent advocate, I would ensure that comprehensive and compelling data is furnished to support my assertions. One such invaluable data source is a groundbreaking study published in the Future Healthcare Journal (2019), a study that unequivocally demonstrated a remarkable 15% decrease in the 30-day rehospitalization readmission rate for the revered cohort of adults aged over 65 who were fortunate enough to have

received a timely follow-up call and subsequent visit from a compassionate discharge nurse within the pivotal first 48 hours after being discharged from the hospital and returning back to their beloved homes and families. By fabricating and implementing this innovative GDN role, an undeniable and inescapable truth emerges although the creation of this new job designation undeniably incurs an additional financial expense—naturally raising eyebrows—any cautious and meticulous analysis insinuates that the return on investment is indubitably substantial. The seamless integration of the GDN role into the fabric of our institution would unequivocally and demonstrably prove to be economically advantageous, particularly by significantly diminishing, mitigating, and ultimately eradicating the surging tide of value-based monetary penalties that are intrinsically linked and inextricably tied to the disheartening rates of rehospitalization. Considering this, it becomes crystal clear that this ground-breaking initiative is not only imperative from a humanitarian standpoint but also a prudent and astute decision when considering the financial well-being and overall prosperity of our revered organization. A5. Value-Based Care Enhancement The proposed change could greatly enhance the concept of value-based care by 1) prioritizing and emphasizing patient-centered care. The role of the GDN would not only encompass addressing the physical needs of the patient, but it would also extensively assess the various social determinants of care that might have a profound impact on each unique individual after their discharge from the healthcare facility. By meticulously addressing and thoughtfully planning for all potential obstacles that a patient may encounter upon their return home, the GDN effectively minimizes the likelihood of rehospitalization, thereby significantly bolstering the overall quality and effectiveness of value-based care. This holistic approach ensures that every aspect of the patient's well-being is taken into account, ultimately leading to optimal health outcomes and an enhanced patient experience.

2) Additional benefits come in the form of cost-effective services for the healthcare organization. Through the implementation of patient-centered care and the subsequent reduction in rehospitalization rates, the GDN proves instrumental in not only delivering exceptional quality care but also in optimizing financial efficiency. The hospital greatly benefits from this dynamic symbiosis by effectively and strategically decreasing its organizational costs while simultaneously preserving valuable hospital resources. This multifaceted approach not only brings about financial advantages for the healthcare organization, but it also reinforces the sustainability and long-term viability of its operations. The mutually beneficial relationship established between the hospital and the patient is reinforced by the inherent reduction in costs without compromising the high standards of quality patient care. This equilibrium between cost savings and quality outcomes creates a positive feedback loop that continuously reinforces the value-based care model. Consequently, both the hospital and the patient become intrinsic beneficiaries of this progressive paradigm, as they share in the collective achievement of reducing overall healthcare costs while simultaneously enhancing the patient experience and optimizing health outcomes. This comprehensive approach redefines the very essence of value-based care and marks a significant step forward in the evolution of the healthcare industry. A6. Key Stakeholder Identification The key stakeholders in my proposal are as follows: 1) The facility's chief nursing officer (CNO). She would not only play a crucial role in approving the GDN role and creating a comprehensive GDN job description but also review the 30-day readmission rate data on a quarterly basis. Her expertise and guidance would significantly impact the success of the proposed plan. 2) The provider, being an essential component of the healthcare team, would have the responsibility of specifying the medications, follow-up appointments, and disease processes that need to be addressed

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in the discharge plan. Their expert knowledge and input would ensure the seamless transition of care from the hospital setting to the patient's home. 3) The GDN, or the discharge nurse, would play a pivotal role throughout the patient's hospital stay and after discharge. Apart from assessing the patient's needs, the GDN would be responsible for addressing any health and safety concerns, providing necessary education, and connecting the patient with relevant community resources, thus promoting a holistic approach to healthcare. 4) Finally, it is crucial to acknowledge the patient and the patient's family as significant stakeholders in this proposal. Their active participation and collaboration with the healthcare team, including the provider and GDN, are fundamental in meeting their specific healthcare needs. By fostering a patient- centered approach, the proposed plan would empower patients and their families to actively engage in their own care and recovery journey. Overall, this collaborative effort would contribute to improved patient outcomes and satisfaction levels. A6a. Stakeholder Collaboration Initially, I would start by meeting with the Chief Nursing Officer (CNO) to discuss my proposal and outline the numerous organizational benefits that would stem from implementing such an innovative approach. After gaining the CNO's wholehearted approval, we would meticulously and thoughtfully select a highly qualified candidate who possesses extensive experience and expertise in geriatric care to assume the pivotal role of the Geriatric Discharge Nurse (GDN). Upon completion of this crucial step, I would then humbly request a meeting with the revered CNO, the esteemed healthcare provider, and the aforementioned GDN to engage in a comprehensive discussion that delves deeper into the purpose and expectations of this groundbreaking proposal. I would hold this meeting with immense enthusiasm and an open mind, eagerly inviting and embracing any valuable input or insights they may be inclined to share.

In my unyielding pursuit of cultivating inclusiveness and promoting collaboration, I would proceed with great care by selecting a diverse and representative group of geriatric patients. I would then devote my undivided attention to engaging in meaningful conversations with these remarkable individuals, wholeheartedly listening to their unique stories, experiences, and perspectives. It is through these purposeful interactions that I aim to gain invaluable insight into what they, as esteemed members of our aging population, genuinely perceive as their most pressing needs and concerns when transitioning from the comforting embrace of the hospital environment to the familiarity of their cherished homes. Equipped with this newfound wisdom and understanding, I would conscientiously evaluate and analyze the focal points of our discharge program, judiciously considering adjustments or enhancements wherever needed. Once satisfied that the discharge program aligns impeccably with the specific needs of our cherished geriatric patients, I would eagerly set it into motion, enacting the impeccably crafted discharge plan with unwavering dedication and professionalism. As with any nascent endeavor, it is important to acknowledge and embrace the possibility of necessary addendums to the discharge program over time. The dynamic nature of our profession calls for continuous growth and an ever-increasing understanding of the evolving needs of our aging population. Therefore, these anticipated changes should be viewed not as obstacles but rather as opportunities for improvement, as we gain profound insight and refine our approach to ensure the unwavering welfare and well-being of our beloved geriatric patients. B1. Implementation Resources To implement this change, I would start by selecting one unit to test the new proposal on. I would then utilize EPIC data to identify high-risk elderly patients who plan to be discharged home (excluding those who will go to a skilled nursing facility). Once the Geriatric Discharge Navigator (GDN) is established, the nurse will receive a discharge list and a list of community resources, which will be compiled in collaboration with the case management team. To evaluate the computer literacy skills of

geriatric patients, the GDN will be equipped with company iPads (already available for use on all units) to help patients set up a MyChart account specific to the facility. MyChart, utilized throughout our healthcare system, is an interface platform that enables providers to exchange health information via electronic medical records. Through their unique patient portal, the patient can communicate with providers and nurses, schedule appointments (including telehealth), and review their medications, lab work, and imaging results. Assisting geriatric patients in creating their MyChart account and teaching them how to use this tool will empower them to advocate for their own healthcare. Furthermore, it also offers them a means to participate in virtual visits at home if transportation is an issue, ensuring that they receive the necessary medical attention. Additionally, EPIC provides the GDN with access to educational printouts at a 5th-grade health literacy level, complete with pictures to enhance comprehension. These educational materials will be accessible to the patient through their MyChart account, allowing them to access crucial information about their health in a more comprehensive and user-friendly manner. By expanding the use of technology and improving access to resources such as MyChart and educational materials, we can ensure that geriatric patients are better equipped to manage their healthcare effectively and actively participate in their treatment plans. This approach emphasizes patient empowerment and provides a valuable platform for communication and engagement between healthcare providers and their elderly patients. B2. Implementation Costs Aside from the GDN’s salary, there would be very little cost involved with implementing this proposal. The average registered nurse salary in the US is approximately $71,000 per year, although more experienced nurses can make up to $95,000 annually. We should also factor in mileage, as the GDN would be expected to make an in-home follow-up visit within 48 hours after discharge. Per the Department of Health and Human Resources, which utilizes the IRS reimbursement rate, the mileage

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reimbursement rate is 65.5 cents per mile. All other resources (such as an iPad and educational material) are already available to the nurse through the organization. Therefore, the cost of implementing this proposal is minimal and well within the budgetary constraints. This ensures that the GDN can effectively carry out their responsibilities without incurring significant additional expenses. B3. Implementation Benefits Two benefits of my proposed plan would be increased continuity of care and decreased hospital readmission rates. I firmly believe that by implementing this plan, the continuity of care will significantly improve as the hospital nurse would closely follow the patient from the moment of admission until their discharge to their home. Even after discharge, the step of care will not end there as the General Duty Nurse (GDN) would continue to provide support and follow up with the patient for a period of up to 14 days. This approach is distinct from the usual practice where independent home health companies take over the patient's care after discharge. However, the GDN, who has already assessed and accompanied the patient through their hospital journey, is in a much better position to offer comprehensive and patient-centered care. It is crucial to highlight that it is in the best interest of the hospital to provide a nurse from their own organization for at-home care. By doing so, they can implement preemptive measures and take preventive actions to avoid readmissions. This is especially important as independent home health companies may not have the same vested interest or commitment to preventing rehospitalization as the hospital does. Through this unique relationship established from day one of admission, the GDN is able to thoroughly understand the patient's entire course of treatment, thereby ensuring a seamless continuity of care. The advantage of having the GDN involved throughout the patient's healthcare journey is that they are in a prime position to identify any specific needs or potential barriers that may exist. Armed with this comprehensive knowledge, the GDN can utilize this information to provide the necessary resources and

educational opportunities to the patient and their family. Consequently, this approach significantly increases the probability of preventing rehospitalization and improves the overall outcome of the patient's healthcare experience. By prioritizing the patient's well-being and leveraging their understanding of all phases of the patient's healthcare journey, the GDN can provide a level of care that goes beyond the mere surface, ensuring an optimal level of support and preventing unnecessary readmissions. B4. Implementation Phases Planning (months 1-4) This phase will include presenting the Chief Nursing Officer (CNO) with the GDN proposal and gaining approval. After approval, the job role must be created to include detailed role expectations, responsibilities, and qualifications. The job would then be posted on various platforms to attract potential candidates, and after a thorough interviewing process, a highly qualified and experienced individual would be selected for the position. To ensure the success of the new proposal, an after-hospital patient survey will be meticulously designed and prepared to collect valuable feedback from the patients involved in the new proposal initiative. This feedback will provide valuable insights and help in making necessary improvements. Additionally, during this phase, a milestone will be reached as the specific unit in which the GDN will perform their duties will be chosen. To better understand the discharge process, the GDN will have the opportunity to shadow a unit nurse who is experienced in this field. This will enable the GDN to gain first-hand knowledge and insights regarding the various aspects of the discharge process, enhancing their skills and expertise. Implementation (months 5-8) In this phase, significant progress will be made towards the successful execution of the GDN proposal. A milestone will be achieved as the patients who will be part of the trial for the GDN proposal are carefully chosen. The GDN will officially begin functioning in their designated job role, applying their knowledge, skills, and expertise to positively impact patient care. As part of the interdisciplinary team (IDT), regular meetings will be conducted to discuss patient-specific hospital and

discharge goals. The IDT meetings will also involve case management, who will not only provide valuable insights but also share crucial community resource information. Additionally, case management will offer medication coupons to facilitate a smooth transition upon discharge. Weekly IDT meetings will be held to review patient cases and assess the progress made, ensuring that individualized plans of care are updated whenever necessary, to provide the best possible care and support for each patient. Evaluation (months 9-12) This crucial phase involves evaluating the effectiveness and overall impact of the GDN proposal. The CNO, in collaboration with the IDT, will review the specified patients included in the proposal, focusing on the rehospitalization readmission rate (RRR) data. This thorough analysis will provide valuable insights into the effectiveness of the proposal and help identify areas that require improvement. The CNO and the IDT will meet to discuss the 30, 60, and 90-day RRR, analyzing the data to gauge the success of the proposal. Patient surveys will play a crucial role during this evaluation phase as well. The input and feedback from these surveys will be taken into consideration when revising or adding to the discharge proposal plan goals, ensuring that patient needs, preferences, and satisfaction are prioritized. This comprehensive evaluation process will enable the healthcare institution to adapt and refine the GDN proposal, leading to enhanced patient outcomes and improved healthcare delivery. B5. Implementation Data The quarterly data, which is being provided by the Chief Nursing Officer (CNO), regarding the Readmission Reduction Ratio (RRR), will be analyzed and utilized to determine if the role of the Geriatric Nurse (GDN) is effectively preventing rehospitalizations. Moreover, the insightful patient survey will not only serve as a valuable learning tool but also present additional opportunities for patient education. The collected data from the survey will be carefully examined to identify potential areas of improvement in order to better meet the diverse and specific needs of each patient during the transition from the hospital to their home upon discharge.

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B6a. Financial Benefits The financial benefit is the decreased cost to the healthcare organization because of reducing the RRR. With incentivized value-based care, avoiding just one Medicare rehospitalization can gain the hospital a financial reimbursement rate between $10,000-$58,000. The geriatric patient also benefits financially by reducing the cost of copayments associated with hospital stays. Most senior citizens are living on fixed incomes, with 55% relying on social security alone, forcing many seniors to choose between healthcare or the necessities of living. This financial burden leads to a significant impact on their overall well-being, affecting their ability to afford essential expenses such as housing, utilities, and food. Additionally, the high costs of healthcare can result in the accumulation of medical debt that can further worsen their financial situation. Therefore, reducing the financial strain of healthcare expenses through measures such as minimizing hospital readmissions can greatly improve financial stability and quality of life for geriatric patients. B6b. Ethical Implications Two potential ethical implications of the proposed plan are 1) does the proposed role of the GDN benefit the hospital or the patient? 2) Does the proposed GDN benefit those patients whose insurance does not offer the hospital value-based financial incentives for RRR reduction? The answer to both ethical questions is yes, both Medicare and non-Medicare patients benefit from the GDN role. Does the hospital benefit too? Absolutely, but not at the expense of the patient, which is why value-based care works. While financial reward should not be the driving force for providing excellent patient care, physicians do have an obligation to protect the patient’s best interests when providing care. This includes reducing the medical costs incurred by the patient. Examples of reducing costs for the patient would be not ordering duplicate tests, or lab work, or charging the patient for any other unnecessary medical expenses. By implementing the GDN in the patient’s care plan, the physician is attempting beneficence by reducing any further avoidable medical expense to the patient, including the cost

associated with RRR. Both Medicare and non-Medicare patients reap this financial benefit, regardless of whether the hospital profits from their successful health outcome. Furthermore, it is crucial to acknowledge that the implementation of the GDN also has social ramifications. The proposed plan ensures the equitable distribution of medical resources and access to healthcare services for all patients, regardless of their insurance coverage. This commitment to fairness and equal treatment is an essential ethical consideration when evaluating the GDN's role in the hospital. Additionally, the ethical implications extend beyond the financial aspect. The GDN promotes patient- centered care by prioritizing the patient's well-being and minimizing unnecessary medical procedures or treatments. This approach embodies the principles of autonomy and non-maleficence, ensuring that patients receive the most appropriate and effective care without subjecting them to undue harm or burden. Moreover, the GDN plays a crucial role in fostering a collaborative and transparent relationship between healthcare providers and patients. By integrating the GDN into the care plan, physicians enhance communication and shared decision-making with their patients. This patient-physician partnership empowers individuals to actively participate in their healthcare journey, promoting patient autonomy and informed decision-making. Furthermore, the GDN aligns with the broader healthcare goals of population health management and preventive care. By identifying and addressing risk factors through the GDN, physicians can proactively intervene and mitigate potential adverse health outcomes among the patient population. This proactive approach reduces the reliance on reactive, costly interventions and promotes long-term health and well-being for patients. In conclusion, the proposed plan involving the GDN raises important ethical considerations regarding its impact on both the hospital and the patient. However, through the implementation of value-based care principles, the GDN prioritizes patient well-being while simultaneously benefiting both Medicare

and non-Medicare patients. By reducing avoidable medical expenses, promoting equitable access to healthcare, and fostering patient-centered care, the GDN exemplifies ethical principles such as beneficence, autonomy, non-maleficence, and justice. As a result, the GDN contributes to improved patient outcomes, enhanced patient-physician relationships, and the overall advancement of healthcare practices. B7. Technology Integration The use of iPads in the hospital would be a pivotal and integral part of the proposal, ensuring that geriatric patients can access and utilize their patient portal on MyChart, which plays an absolutely crucial and fundamental role in communicating, managing, and self-advocating for their healthcare needs and requirements. As previously outlined and emphasized in section B1, Implementation Resources, it will be the responsibility and duty of the Geriatric Digital Navigator (GDN) to assess the patient’s level of computer literacy skills diligently and comprehensively by diligently and patiently assisting the patient with the setup process of their MyChart patient portal and providing them with a thorough and detailed tutorial on the efficient and effective use of MyChart. However, it is of utmost importance to acknowledge and recognize an obstacle that has unfortunately been overlooked in this proposal, which pertains to the geriatric patient's ability to access digital resources and maintain connectivity once they have been discharged from the hospital. In my strongly held belief, the issue of access to digital resources and connectivity should undeniably be encompassed within the realm of social determinants of health, considering its immense significance and impact on the overall well-being and comprehensive healthcare management of geriatric patients. It is worth noting that as discussed earlier in this paper, our geriatric population is particularly vulnerable and susceptible to experiencing a significant healthcare disparity, especially due to the fact that over 50% of them solely rely on social security as their primary source of income, further exacerbating this critical issue. Nonetheless, it is imperative to comprehend that bridging the prevailing

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digital divide is an immensely intricate and multifaceted process that requires comprehensive and holistic approaches, warrants attention, and demand separate endeavors that should be addressed distinctly and independently from the context of this paper. Henceforth, it is incumbent upon the GDN to perpetually strive and steadfastly endeavor to offer the best possible efforts and recommendations in order to address and mitigate this substantial digital discrepancy. One such recommendation would be to provide the geriatric patients with pertinent information and details about outpatient community resources, which are readily available and accessible for them to utilize as needed. This, at the very least, would aspire to ameliorate and alleviate the burdensome consequences of this prevalent healthcare disparity, hopefully fostering a more equitable and inclusive healthcare experience for our geriatric population. B8. Measure Success The first way in which I would measure success would be by reviewing RRR quarterly. If the rates are down, then we know the GDN role has proved successful in reducing rehospitalization rates! It is also important to base measured success on patient surveys as well. We should use the survey feedback to make meaningful improvements. After all, the patient is our focus, and whether they feel supported by the healthcare community and competent in managing their disease processes outside of the hospital is of major significance. Understanding the unique needs of our aging patients and tailoring the discharge experience to meet those needs is ultimately what makes this program successful. Additionally, we must ensure that effective communication channels are in place to address any concerns or issues that may arise. This includes providing clear instructions and resources to patients and their family members upon discharge to ensure a smooth transition from hospital to home care. To further enhance the success of the program, we can also consider implementing a comprehensive follow-up system. This would involve regular check-ins with patient’s post-discharge to assess their progress, provide additional support if needed, and address any potential gaps in their care plan. By

taking a proactive approach in measuring success and continuously improving our processes, we can optimize patient outcomes and ensure the long-term success of the program. C1. Change Agent I found that through creating this proposal, I gained confidence in my abilities to be a change agent. I derived immense satisfaction from discussing my proposal with management as this collaborative process lends unique perspectives on how to maintain, and even improve, safe, high-quality, patient- centered care while also reducing organizational costs. I firmly believe that one of the most significant change agent factors in my proposal lies in recognizing and implementing a comprehensive plan to holistically address the issue of geriatric computer literacy, taking into account various socio-economic and demographic factors. It is paramount to acknowledge that many individuals in this age group often lack the fundamental computer skills needed to efficiently utilize online healthcare tools, a predicament that unfortunately often goes unnoticed in the healthcare setting. Allow me to provide a relevant example to highlight the importance of my proposal. Central to my plan is the integration of the Geriatric Digital Navigator (GDN) whose primary responsibility would be to assess and address the specific computer literacy needs of each patient. By extending personalized assistance, the GDN would guide and aid geriatric patients in setting up their MyChart patient portal accounts, thereby enhancing their accessibility and ushering them into a world of seemingly boundless possibilities. This multifaceted healthcare tool not only empowers geriatric patients in effectively managing their medications and chronic diseases within the comfort of their homes but also facilitates seamless communication with their healthcare provider(s) and enables them to participate in telehealth appointments, should the need arise. Consequently, the barriers posed by logistical challenges, such as finding transportation for medical appointments, and the pervasive social isolation often experienced by the elderly are markedly reduced. By systematically addressing these issues, we, as a progressive

healthcare system, move steadily closer to overcoming the various barriers and disparities that are frequently encountered by those directly impacted by social determinants of health. C2a. Knowledge and Skills I was able to utilize the invaluable knowledge and insights I acquired during my comprehensive education in the field of Global and Population Health to effectively and astutely identify various at-risk populations and comprehend the multifaceted social determinants of health that these populations encounter and struggle with daily. One illustrative example of this is my deliberate decision to address the prevalent issue of lack of transportation, social isolation, and potential computer literacy skill deficit among the elderly demographic. By targeting and addressing these interconnected determinants, I was able to improve the overall health outcomes of this vulnerable population substantially and comprehensively, going beyond the mere focus on their obvious physical needs. It is crucial to acknowledge that although meeting the physical needs of individuals is undoubtedly imperative, it does not independently guarantee a positive and holistic health outcome. As diligent and accomplished bachelor-educated nurses, we possess the necessary aptitude and specialized training to look beyond the surface and incorporate the psychological and socioeconomic factors that significantly influence the health status of our patients. With my vast accumulation of knowledge and proficiencies throughout my extensive academic journey, which encompassed an in- depth understanding of statistics and the economics of healthcare organizations, I acquired the capability to effectively comprehend the multifaceted framework of healthcare economics and formulate coherent and measurable goals. Consequently, armed with these insights, I successfully executed a meticulously crafted proposal that undeniably and mutually benefits both the healthcare organization and the patients it serves.

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C2b. Proposal Expansion My proposal begins in the hospital with a geriatric nurse following the patient from admission to discharge, including up to 14 days after returning home. This proposal is based on what tools the hospital nurse can provide the patient within order to make their recovery a successful one. As I worked on this proposal, I naturally found myself envisioning bigger and better things. Armed now with the understanding of the impact of social determinants on health, I began envisioning a partnership with my organization and others in the community. What if, based on income, we partnered with Verizon or T- Mobile to provide underprivileged patients with broadband access? What if we lobbied for Medicare to include an iPad or Chromebook as part of their covered benefits? What if we partnered with a local computer “doctor” to provide the underprivileged with a refurbished electronic device? Surely there is some kind of tax write-off that would prove financially beneficial for a local business willing to partner with the hospital to improve the lives of the impoverished. To help answer these questions and the many more that would certainly pop up, we would need to enlist the help of accountants and attorneys to assist in navigating these unknown waters. However, I do believe there are plenty of scholarly studies already written proving the importance of digital resources in improving community-based care. By improving community-based health, we change the future of healthcare by saving lives while also reducing healthcare costs. The challenge is finding our collaborative voice and presenting the evidence that makes those in power listen. Additionally, in exploring these possibilities, we must consider the potential benefits of partnering with local educational institutions to provide healthcare training and resources to the underprivileged population. This could involve collaborating with vocational schools and universities to offer scholarships and educational programs in healthcare fields, ensuring a pipeline of qualified professionals who can contribute to community-based care. Moreover, we could establish mentoring programs, where

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experienced healthcare practitioners guide and support aspiring individuals from disadvantaged backgrounds, empowering them to pursue rewarding careers in the healthcare industry. Furthermore, as we strive to address the social determinants of health, it is crucial to acknowledge the significance of affordable housing. By partnering with housing organizations and real estate developers, we can work towards creating affordable, safe, and sustainable housing options for low- income individuals and families. These initiatives would not only provide stability and improved living conditions but also foster a sense of community and belonging, essential for overall well-being and holistic healthcare. To maximize the impact of our efforts, it is vital to engage community leaders, policymakers, and advocacy groups. By forming coalitions and task forces focused on health equity, we can collectively devise strategies to address systemic inequalities and bring about positive change. Additionally, leveraging the power of social media and online platforms, we can raise awareness about the importance of community-based care, mobilize support, and amplify the voices of those affected by healthcare disparities. In conclusion, by expanding our vision and collaborating with various stakeholders, we can revolutionize community-based care and transform the future of healthcare. Through innovative partnerships, educational initiatives, and advocacy efforts, we can provide underprivileged individuals with the resources and opportunities needed for better health outcomes. By dismantling barriers and amplifying the collective voice of communities, we can foster a society where every individual has equal access to quality healthcare, regardless of their socioeconomic status. Together, we can create a future where healthcare is truly inclusive and where everyone can thrive and lead healthier lives.

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References Demographic Turning Points for the United States: Population Projections for 2020 to 2060 (February 2020, Jonathan Vespa, David M. Armstrong, and Lauren Medina) Pottle J. Virtual reality and the transformation of medical education. Future Healthc J. 2019 Oct;6(3):181-185. doi: 10.7861/fhj.2019-0036. PMID: 31660522; PMCID: PMC6798020. For additional information on APA Style formatting, please consult the APA Style Manual, 7th Edition .

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Capstone Task 1

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