DescriptionPurpose of Project: The purpose of this project was to evaluate the effectiveness of an evidence-based intervention in reducing 30-day readmission rates among post hospital discharge heart failure patients in a Medical Group.
Methodology: This project utilized a retrospective exploratory design to evaluate the effectiveness of an evidence-based intervention to reduce 30-day readmission rates among post hospital discharge HF patients in the Medical Group. A descriptive comparative analysis was conducted on outcomes data from pre-implementation, June 2017-June 2018 and post-implementation, July 2018-December 2019, in order to evaluate the intervention.
Results: During the pre-implementation period (June 2017-June 2018) the twelve patients who qualified for the study had been re-admitted on several occasions. Of the twelve, six had never been hospitalized, four patients were readmitted within 30 days of discharge, but one patient had multiple visits to the emergency room (ER).
After the implementation of the transition care intervention, readmission rates, including hospitalization and visits to the ER, were reduced to zero. In addition, the patient who had multiple visits to the ER, was not readmitted to the hospital or had to visit the ER within 30 days after the intervention. With four patients, who were readmitted within 30 days during the pre-implementation period, the readmission rate was 33%. There were no readmissions within 30 days post implementation. Overall, there was an improvement in reducing readmission rates within 30 days after the implementation of the transition care intervention in the Medical Group.
Implications for Practice: By implementing the TCI, it can potentially utilize by the hospitals, medical groups, and homecare agencies to reduce readmission rates of patients with HF. The TCI will be beneficial to improve quality of care, increase patient outcomes and increase patients’ satisfaction. Lastly, the TCI will be beneficial for the organization in reducing healthcare costs due to readmission rates posthospital discharge.