4691 Bachelor Of Nursing

Develop a care coordination program to decrease the hospital readmission rate for patients with Congestive Heart Failure. Using the eight Transitional Care Model in Module and the Principles of Screening and Referral.

Answer

Congestive heart failure is one of the major issues, which creates a burden on the health care system. It refers to the chronic progressive condition that affects an individual’s pumping of heart muscles. Thus, developing a care coordination program will focus on reducing the hospital readmission rates of the patients with the congestive heart failure (Scott and Winters, 2015).

The care coordination program is developed by using a transition care model, and the screening and referrals. Transitional care model or interventions are based on evidences, and they are designed to ensure coordination and care of their patients when they are transferred to levels of care. The first step includes treating the patients with the underlying causes (CHF, HTN, and Diabetes). Then managing and controlling the symptoms of the congestive heart failure of the patient, examining the halt or slow progression of disease. Achieving the satisfactory improvement of the quality measures includes 30-day mortality and decreased 30-day readmissions for CHF (Vedel and Khanassov, 2015).

Ensuring the quality of care provided to the patients, through improved self-care methods, such as adherence to medication, and compliance with the plan of treatment of the disease. The plan should be focused towards decreasing the cost of care provided to the patients, through assessment, engagement interventions, clinical methods, and referrals. Then the last step is to reduce the morbidity and mortality. The plan or program to prevent the increasing rate of heart failure also includes essential steps of Screening and referrals. It includes identifying and targeting the specific population of a group of people, older adults in such cases who are at risk for these poor outcomes (Hall et al., 2018).  

The transition care program for congestive heart failure patients include, eight aspects or components to disease management after hospital discharge, and reduce readmission rates. Telephone follow-up, which states that the patients are contacted through telephone call to know about their health after treatment. It then follows with providing them education about their health management, which includes further the aspects of self-management. Weight monitoring is the next component of the aspects of transition care program to reduce the readmission rates in the hospital. Sodium restrictions, advices for healthy diet, and following   recommended exercises, medication review, and the social, psychological support are the eight components that should be considered. These components and the care must be provided to the patients considering the fact that the principles of screening and referral must be considered important. Patients must be screened out those who require special treatments, other than what is available to them. Referring them to the multi-disciplinary heart failure team, requires initial diagnosis of heart failure, management of heart failure, especially which does not respond to the given treatment. Including the heart failure, that is not manageable effectively within the home-settings (Coghlan et al., 2014). 

References

Hall, E.C., Tyrrell, R., Scalea, T.M. and Stein, D.M. (2018). Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission. Trauma surgery & acute care open, 3(1), 149.

Scott, M.C. and Winters, M.E. (2015). Congestive heart failure. Emergency Medicine Clinics, 33(3), 553-562.

Vedel, I. and Khanassov, V. (2015). Transitional care for patients with congestive heart failure: a systematic review and meta-analysis. The Annals of Family Medicine, 13(6), 562-571.

Coghlan, J. G., Denton, C. P., Grünig, E., Bonderman, D., Distler, O., Khanna, D. & Chadha-Boreham, H. (2014). Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis: the DETECT study. Annals of the rheumatic diseases, 73(7), 1340-1349.