CPE PHASE 2 D028

Phase 2 Readmission Prevention Planning Center for Medicare and Medicaid Services (CMS) has put an emphasis on reducing the number of readmissions to hospitals with in a 30-day time. The reason for this focus is that a readmission within 30-days indicates either incomplete treatment or lack of discharge planning/teaching by the care team. One incentive used by CMS to reduce the number of readmissions is a financial penalty to hospitals who do not meet the standard set for their program (CMS, 2023). The changes in CMS standards have lead health care teams and leaders to research and trial evidence-based practice techniques to reduce readmissions related to specific disease processes. For patient C.S., a 74-year-old African American female newly diagnosed heart failure patient we will explore some of these tactics to reduce the event of readmission. Goldgrab, Balakumaran, Kim, & Tabtabai (2019), explain in their research that often when heart failure patients are readmitted within 30-days they experience a higher mortality rate than patients who are not readmitted in that time frame. This is explained by a better understanding of care and compliance with discharge planning. Ryan et al. (2013), further emphasized this with a study that showed a hospital readmission rate for heart failure drop 8% by implementing a 7-day follow-up visit plan for all heart failure patients. At these visits discharge instruction from the hospital were reviewed and reinforced with patients, which helped ensure compliance and understanding. Many facilities nationwide have implemented post-discharge phone calls within 48 hours of discharge to ensure patients understand their discharge planning, as well as were able to fill all prescriptions, schedule follow-up appointments, and contact any home health services needed. For heart failure patients These phone calls are often made by a site-specific navigator who will be able to answer questions from the patient should they need.

It is important when performing discharge planning and follow up that all elements of social determinants are explored. The following chart is patient specific to our patient C.S. and addresses five factors identified for her along with plans to help prevent 30-day readmission. These interventions require a collaborative effort between physician, nursing, therapies, social services, and case management. Discharge Planning Focused Interventions Social Determinants Individual Social and Community Systems Economic Stability  Medication Expenses  Increased food expense related to low-sodium low- fat diet.  Patient assistance programs  Use of medication discount cards when available.  Social workers to identify/provide programs in the community that assist with heart health meals delivered to home. Education  Patient discharge instructions that include a complete medication reconciliation, follow-up appointments, and dietary recommendations.  Exercise programs in the community for seniors to promote lifestyle modifications.  Coordination by social services/case management for admission to inpatient rehab for strengthening. System Level  Cardiology and PCP follow up for compliance and symptoms management.  Dietician meeting and education for heart health diet compliance and management.  Discharge follow- up phone call by cardiac navigator 48 hours after discharge. Environment  Community parks and trails to promote exercise and heart health lifestyle.  Transportation assistance to appointments when needed. Utilization of family and community resources.  Social worker to provide information on insurance related resources for transportation. Social/community  Meet with patient and family to  Senior centers that assist with  Social worker to assist with

References Centers for Medicare & Medicaid Services. (2023). Hospital readmissions reduction program (HRRP) . CMS.gov. https://www.cms.gov/medicare/medicare-fee-for-service- payment/acuteinpatientpps/readmissions-reduction-program Goldgrab, D., Balakumaran, K., Kim, M. J., & Tabtabai, S. (2019). Updates in heart failure 30-day readmission prevention. Heart Failure Reviews , 24 (2), 177–187. https://doi.org/10.1007/s10741-018-9754-4 Ryan, J. T., Kang, S., Dolacky, S. D., Ingrassia, J., & Ganeshan, R. (2013). Change in Readmissions and Follow-up Visits as Part of a Heart Failure Readmission Quality Improvement Initiative. The American Journal of Medicine , 126 (11), 989-994.e1. https://doi.org/10.1016/j.amjmed.2013.06.027