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Running Head: CAPSTONE PROJECT: FOSTERING AFTER DISCHARGE FOLLOW UP 1

CAPSTONE PROJECT: FOSTERING POST-DISCHARGE FOLLOW UP 2

Capstone Project: Fostering After Discharge Follow-Up

Dalianis Diaz

Professional Capstone and Practicum Comment by Toniya Koolikunnel Thomas: Write the name of the university followed by colon before the course name.

02/06/2021

 

Capstone Project: Fostering After Discharge Follow-Up

Nonadherence to post-discharge recommendations has been one of the biggest setbacks in the race towards achieving a healthy America. The case is so because despite prescribing the appropriate medications, patients fail to adhere to the set dosages, which results in deteriorated medication effectiveness. Nonadherence can take various forms rather than medication including but not limited to failure to adhere to set appointments, and not following the recommended lifestyle or dietary changes. As a result, nonadherence to post discharge follow up plan does not only have significant financial implications but also results in frequent rehospitalization among other challenges (Jimmy & Jose, 2011). Since, the costs associated with nonadherence to post-discharge recommendations are high, it is essential to implement measures to foster adherence to after discharge plans through incorporating self-management strategy in the healthcare settings in order to enhance the overall effectiveness of the healthcare interventions. Comment by Toniya Koolikunnel Thomas: Good introduction

Background

Medications nonadherence has overtime been reported to range between 20 to 50 percent, with 75 percent of U.S residents reporting to exhibit difficulties taking their medication as directed by their providers. Such a number is high given that nonadherence can have far-reaching consequences on one’s health and in worst-case scenario, it can result in death. Failure to adhere to after discharge follow-up plans is estimated to contribute to a staggering 125,000 deaths annually. Besides, about 30 to 69 percent of the America’s total number of medication-related readmission result from poor adherence to post-discharge plans (Oliveira-Filho et al., 2014). The overall cost estimates associated with nonadherence to after discharge follow-up plans ranges between $100 billion and $300 billion annually when both indirect and direct costs are taken into account. By promoting adherence to post-discharge follow-up plans, the above amount can be redirected to other economy-building initiative or even further improve the existing healthcare facilities (Flink & Ekstedt, 2017). Therefore, nonadherence to after-discharge plans has become a national challenge that is blocking achievement of a fit and healthy nation, while preventing excellent patient outcomes.

Clinical Problem Statement

Although adhering to post-discharge follow-up can help improve the patient’s health outcomes, while saving on costs, the current population rarely adheres to the after-discharge plan which triggers far-reaching consequences in both financial and non-financial terms. If the nonadherence problem is not resolved, then the nation and individuals will continue to lose billions of dollars through readmission and other-related costs and the patient outcomes will continue to suffer greatly. Comment by Toniya Koolikunnel Thomas: can even lead to death due to serious complications. You can elaborate on the selected clinical problem.

Purpose of Change Proposal

The purpose of the proposed change project is to integrate a self-management strategy in the healthcare setting to facilitate post-discharge adherence to the recommended follow-up plan. The proposed patient self-management project is aimed at preparing patients and training them for an out-of-hospital experience that will encourage them to adhere to follow-up plans. Since the patients will be imparted with critical knowledge about their health condition and design a follow-up plan that suits their daily routine, collaboration between them and their healthcare providers will be promoted, thus facilitating overall adherence. Comment by Toniya Koolikunnel Thomas: You can also include the effects of overall adherence. Capstone Project Presentation Feedback

Picot Question

When dealing with the homeless, African Americans and Haitians struggling with various behavioral problems. Is a standard discharge letter effective than imparting self-management skills to patients in facilitating post-discharge medication adherence? The population in question comprises of poor and illiterate individuals, which makes it difficult to them to decode standard discharge letters containing the follow-up plan, which makes it an inefficient approach to facilitating adherence. The proposed intervention is a self-management program that will see the population get educated about the necessary information through various ways including integrating a customized post-discharge follow-up plan that matches their daily routine and sending reminders to patients about their upcoming post-discharge interventions such as appointment and medication refilling.

Since standard discharge letters have been in existence for years, yet nonadherence to after-discharge plans continues to be rampant on a daily basis, it is crucial to attempt the new self-management strategy, which will see patients get informed about the importance of adherence and measures to put in place to enhance their ability to adhere to follow-up plans. The expected outcome is to achieve lesser patient rehospitalization due to nonadherence to after discharge plans and promote more adherence, while improving the overall patient outcomes. Comment by Toniya Koolikunnel Thomas: Use the PICOT mnemonic

Literature Search Strategy

The selected topic is associated with after-discharge follow-up. The U.S. National Institutes of Health’s National Library of Medicine (NIM/NLM) was used to search for filtered information, while MEDLINE database and the school library were used to search for unfiltered content. In all databases, the keyword used to search for information was “Post-discharge follow-up adherence.” Every source concluded that there exists a need to modify how post-discharge follow-up plans are disseminated to patients, while quoting it as a major contributor to the rampant nonadherence to such plans. I found 17 results that have been peer-reviewed or critically appraised by experts. The information found in 6 of the 17 results was primarily attributed to

 

medication adherence and plans to improve adherence.

Evaluation of Literature

Jimmy, B., & Jose, J. (2011) researches on patient medication adherence: measures in daily practice. The article is authentic and its information can be trusted because the authors are lectures at University of Nizwa in Oman. Besides, the source is published in a reliable academic journal, the PubMed Central (PMC). Also, it is related to my topic because it addresses patient medication adherence, which is part of the after-discharge follow-up plan.

The article by Flink, M., & Ekstedt, M. (2017) discusses planning for the discharge, not for patient self-management at home. The source by Flink and Eksted is authentic because the authors are affiliated to an academic institution, that is Linnaeus University. Besides, the source has been reviewed by experts. The source is relevant to my research because it addresses preparing for discharge in a way that will foster post-discharge follow-up adherence. Also, it is published in a credible journal, PMC. The sources used in the literature are all trustworthy because before using them, their author’s credentials, their usefulness to the research topic and reliability were all reviewed as their assessment criteria. Comment by Toniya Koolikunnel Thomas: You can talk about other literature and how they support your change proposal.

Applicable Change or Nursing Theory

The applicable change theory in the proposed project is the Lewin’s change theory. The case is so because it involves three main concepts, that is the driving forces, equilibrium and restraining forces. In this case, the driving forces is minimizing nonadherence to after discharge follow-up and its consequences. The restraining force is the use of traditional post-discharge letters as a way of facilitating follow-up adherence. It forms a force that tends to act against the implementation of a new approach to facilitating post-discharge follow-up. The equilibrium in this case is the state where there is a balance between restraining and driving forces. This balance will be achieved upon implementing a strategy that will see improved patient adherence to after-discharge plans.

Proposed Implementation Plan with Outcome Measures

To implement the self-management change project that fosters adherence to after-discharge follow-up plan, a room fitted with all patient education facilities will be created. Secondly, retraining of healthcare professionals will be conducted to prepare them to deliver patient-centered regimen characteristics. Patient and family communication is another thing that will be fostered under the new after-discharge follow-up implementation plan. A help center will then be established to house healthcare support assistants who will be sending reminders to patients, with a future option of automating the process. The outcome measures that will be utilized to assess the effectiveness of the project include the rate of after-discharge rehospitalization, patient satisfaction level, and the adverse cases among the discharged patients. Comment by Toniya Koolikunnel Thomas: Good implementation plan. Capstone Project Presentation Feedback

How Evidence-Based Practice was Used in the Creation of the Intervention Plan

When creating the intervention plan, several Evidence-Based Practice (EBP) were involved. One of the is that a medical question was posed that triggered identification of a problem. The question was, “why is there high rate of nonadherence to post-discharge follow-up?” Secondly, evidence was gathered from various authentic sources and analyzed to determine the primary factor leading to patient nonadherence. Furthermore, the types of research used in EBP was similar to those used in the research. Randomized control trials and opinions from medical experts, that are in line with reports, studies, and experiences were some of the research methodologies that were utilized in the development of the intervention plan. Comment by Toniya Koolikunnel Thomas: Please describe how you used EBP in the intervention plan.

Plan for Evaluating the Proposed Nursing Intervention

The plan to evaluate the proposed intervention is will assess the relationship between various activities undertaken during the implementation phase and the outcome measures, goals, activities, objectives, and impacts. It will be made up of four steps, that is selection of outcomes and impacts, identification of the evaluation method, and compiling a report consisting of the evaluation outcomes. In the impact an outcome identification step, the two aspects will be selected based on the project’s goals such as reduction of cost and readmission rates. The selection of the evaluation method will involve identifying the most appropriate method that can facilitate effective measurement of the project’s outcome and effect on patient’s health status. In this case, randomized controlled trials will be used with both post- and pretests being done to assess the effectiveness of the proposed intervention (Lavinghouze & Snyder, 2013). Evaluation tools including interviews and questionnaires will also be deployed to determine the intervention’s impact. Capstone Project Presentation Feedback

Potential Barriers to Plan Implementation and Strategies to Overcome Them

One of the key barriers to the implementation of the project is resources. The case is so because there exists a need to create a new health system in the facility to include a help center, retrain healthcare professionals, which will spike the cost. To address this issue, a cost benefit analysis will be conducted to evaluate the respective direct and indirect costs and benefits associated with the project. Due to the huge amounts of benefits attributed with the project, I will work closely with the management to extend the resources allocated to the project, when need arises.

Secondly, changing patient beliefs is another barrier to implementation of the plan. The case is so because patients are accustomed to various beliefs and complex routines that are difficult to change. To address this barrier, healthcare workers will be trained on their communication to enhance their ability to address diverse communities. Doing so will enable them to change their beliefs with undermining the existing ones.

Conclusion

Since, the costs associated with nonadherence to post-discharge recommendations are high, it is essential to implement measures to foster adherence to after discharge plans through incorporating self-management strategy in the healthcare settings in order to enhance the overall effectiveness of the healthcare interventions. There is a high rate of nonadherence to post-discharge follow-up plans among patients due to various reasons including but not limited to lack of understanding about the importance of the follow-up plans. As a result, it costs the U.S. billions of dollars, while negatively affecting the patient’s outcome. The purpose of this project is to integrate a self-management plan that will foster patients’ understanding about the importance of adherence to the provider’s recommendation, while integrating a system that will foster their ability to adhere to the follow-up. Keyword search was used to collect evidence from various sources. The applicable change theory in this case is the Lewin’s theory of change. Various evaluation plans will be used to evaluate the proposed change project, with resources being a major barrier to its implementation. However, since the rate of nonadherence have been high overtime, it is essential to integrate a new patient self-management plan that will prepare patient for after-discharge life and voluntary adherence to follow-up plans. Capstone Project Presentation Feedback

References

Flink, M., & Ekstedt, M. (2017). Planning for the discharge, not for patient self-management at home–an observational and interview study of hospital discharge. International journal of integrated care, 17(6).

Jimmy, B., & Jose, J. (2011). Patient medication adherence: measures in daily practice. Oman medical journal, 26(3), 155.

Lavinghouze, S. R., & Snyder, K. (2013). Developing Your Evaluation Plans: A Critical Component of Public Health Program Infrastructure. American journal of health education, 44(4), 237–243.

Oliveira-Filho, A. D., Morisky, D. E., Costa, F. A., Pacheco, S. T., Neves, S. F., & Lyra-Jr, D. P. (2014). Improving post-discharge medication adherence in patients with CVD: a pilot randomized trial. Arquivos brasileiros de cardiologia, 103(6), 503-512. Comment by Toniya Koolikunnel Thomas: Please include all the references you have used in the previous assignments for your capstone project.