NUR 650 Module 9 Final Project Example

Final Project: A Tiered Care Coordination Program to Reduce Heart Failure Readmissions

[Student Name]

Southern New Hampshire University

NUR 650: Care Coordination and Outcomes Management

Module Nine Final Project

[Instructor Name]

[Date]

Final Project: A Tiered Care Coordination Program to Reduce Heart Failure Readmissions

Heart failure is one of the most common reasons older adults are hospitalized and one of the most common reasons they return. In the composite Brookhaven hospital, 24% of heart failure patients are readmitted within 30 days, a rate that has held for three years, exposes the hospital to federal payment penalties and, more importantly, reflects patients who became sick again at home. This proposal asks the executive team to fund a tiered care coordination program for heart failure. It brings together the analysis, design, measurement and evaluation work completed over the past term and argues that a program built on local root causes, tested transitional care components, reconciliation that reaches primary care and honest evaluation can lower readmissions to 19% within a year at a cost the hospital can recover.

The Problem and Its Causes

The analysis reviewed 400 heart failure discharges and all 96 readmissions from the past year. Readmissions came early, with 41% occurring in the first week, and most patients had seen no clinician before returning. A Pareto analysis showed that most readmissions traced back to four linked gaps: silence between discharge and the end of the first week, confusion about the water pill, weights that were never taken or never acted on, and drugs patients could not afford or obtain. Fewer than a third were seen by any clinician inside a week, and one in four had a medication discrepancy at one week. The process map found that teaching happened in the final hour, follow-up was left to patients to schedule and discharge summaries often reached clinics after the first visit.

The Program

Every eligible patient receives the universal tier, adapted from Project RED, which in a randomized trial cut the combined count of return emergency visits and readmissions over the next month by about 30% (Jack et al., 2009). It includes daily teaching with teach-back from the first hospital day, a follow-up visit booked before discharge within seven days using reserved clinic slots, a pharmacist review of the discharge list against guideline-directed therapy and insurance coverage, a plain-language care plan, an electronic discharge summary sent the same day and a pharmacist call by day three. The 2022 AHA/ACC/HFSA guideline supports guideline-directed medical therapy, early follow-up and multidisciplinary care for patients at high risk (Heidenreich et al., 2022).

Patients flagged by the HOSPITAL score, by the five-item social and functional screen, or by a nurse's concern move up to the second tier: a transitional care nurse who begins coaching in the hospital, a home visit within 72 hours, weekly calls for four weeks and a weight gain protocol that allows the nurse, with the cardiology nurse practitioner, to adjust diuretics before symptoms become severe. This tier borrows the clinical responsiveness of the model tested by Naylor et al. (2004), in which nurse practitioners following older heart failure patients from hospital to home lengthened the time to readmission and lowered costs, at a lower intensity suited to Brookhaven's resources.

Medication Reconciliation Across Settings

Because many medication errors arise after discharge, reconciliation extends beyond the hospital. It begins with a two-source history, typically the bottles from home plus pharmacy fill records, labels each discharge medication as new, changed, continued or stopped, includes a stop list for medications at home and ends with a reconciled list transmitted the same day to the patient's clinic and pharmacy, with confirmation of receipt. Caregivers who manage medications are included in teaching. Discrepancies are measured directly on the day-three call.

Measurement and Evaluation

The measurement set follows Donabedian's structure, process and outcome framework, with process measures for each bundle component and an all-or-none composite, outcomes including 30-day readmission, emergency visits, mortality and the Care Transitions Measure, and balancing measures for length of stay, observation returns and staff time. Evaluation uses an interrupted time series of monthly readmissions spanning three years before launch and a year and a half after, with pneumonia readmissions as a comparison series, because readmissions were already falling nationally under federal policy. Decision rules set in advance determine when results can be credited to the program. Results will be examined by payer, race and rural residence to ensure all groups benefit.

Staffing, Costs and Return

Table 1 estimates annual costs of about $200,000. At Brookhaven's average cost of $14,500 per heart failure readmission, preventing about 14 readmissions a year would cover the program's cost before counting any reduction in federal penalties. Reducing the rate from 24% to 19% among 400 discharges would prevent about 20 readmissions. The estimate is conservative in counting only direct hospital costs, and it will be revisited after the first year using the same attribution rules as the clinical evaluation.

Table 1. Estimated Annual Program Costs

Note. Case management and scheduling work is absorbed within existing positions; reserved clinic slots were negotiated at no direct cost.

Governance and Timeline

The clinical nurse leader will serve as program lead, reporting monthly to the quality committee. Each component has an owner: bedside nurse managers for teaching, case management for appointments, pharmacy for reconciliation and calls and the transitional care nurse for the high-risk tier, supervised by the cardiology section. Implementation will proceed in three phases over six months: small tests of each component on one unit, spread to all medical units and full operation with the evaluation clock starting. A steering group of nursing, pharmacy, cardiology, case management, primary care and a patient representative will meet quarterly to review results and decide on changes.

Risks

The main risks are that components will be delivered inconsistently as attention fades, that clinics will not keep reserved slots, that the transitional care nurse's caseload will exceed capacity and that readmissions will fall less than hoped. Mitigation includes monthly process data shared with each owner, written agreements with clinics, a cap on the high-risk caseload with ranking by risk and a candid evaluation that treats a smaller effect as useful information rather than failure.

Conclusion

This proposal asks for about $200,000 a year to address a problem that harms patients and costs the hospital more than that. It is built on local causes, tested components, reconciliation that reaches primary care, measures that show what is delivered and what changes and an evaluation designed to tell the truth. With clear owners and a phased launch, it gives Brookhaven a realistic path from 24% to 19% and the information to know whether it has arrived.

References

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895-e1032. https://doi.org/10.1161/CIR.0000000000001063

Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., O'Donnell, J. K., Paasche-Orlow, M. K., Manasseh, C., Martin, S., & Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007

Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675-684. https://doi.org/10.1111/j.1532-5415.2004.52202.x