A Quality Improvement Initiative: A Nurse Practitioner Led Interdisciplinary Team to Reduce Readmissions in the Subacute Population

25^th Global Nursing Education, Healthcare and Patient Safety Conference

April 28-29, 2022 | Webinar

Dr. Clare Rovito

Felician University, USA

: Adv Practice Nurs

Abstract :

Statement of the Problem: Hospital Readmissions and Emergency Room Visits are both costly and avoidable in the subacute care population, especially when they occur within the first 30 days after discharge. APN led care can complement care from hospitals and outpatient settings while improving chronic care management and patient centered interdisciplinary care. Individual disease knowledge and self-management of chronic conditions can improve readmission rates for some populations. Changes in the transitional care coordination of the SNF patients are needed to improve the quality of life of the older adult, costs related to illness with age and outcomes to healthcare encounters. Methodology and Theoretical Orientation: Twelve week on site Project Manager working within the Interdisciplinary Team. Interventions were based on the Theoretical Framework Lippitt’s Model of Planned Change (1958) with readmission risk assessed using the LACE scoring tool. Findings: Outcomes were divided into three groups. They were reorganized and analyzed. The new breakdown included patients readmitted plus hospice referrals (n=5) and those not readmitted (n=4). A significant difference in the 30- day outcomes as well as the LACE variable comorbidity scores t (4) =2.95, p=0.0418 were identified. Resident and caregiver Levels of Engagement varied with the DNP Project Manager and Interdisciplinary Team members. Interdisciplinary Team members “Strongly Agreed (82%) and Agreed (18%)” that having the APN/DNP Project Manager on site daily improved the coordination of care and outcomes to care. Conclusion and Significance: APN facilitated education of patients, caregivers and staff can change readmissions rates and improve patient, caregiver, and staff coordination of care. Additionally, APNs can improve care transitions using the application of evidence-based strategies but can be limited by State based Scope of Practice Regulations, nationally. Recommendations are made to allow APN leadership to change outcomes to the National Health Care system

Biography :

Clare E Rovito is a Nurse Practitioner Specialist in USA. She graduated with honors in 2005. Having more than 17 years of diverse experiences, especially in NURSE PRACTITIONER, Clare E Rovito affiliates with no hospital, cooperates with many other doctors and specialists without joining any medical groups.