Running head: Introduction to the Problem Introduction to the Problem Introduction of DNP Project Proposal Identified Need and Problem Statement 1 Introduction to the Problem Although hospitals have been striving to cut the cost, the problem of unscheduled return visits to the Four Corner emergency department has not been completely addressed. Most hospitals in the state of Florida have been concentrating on reducing 30-day readmission with a few activities and intercessions (CDC, 2017). In Florida, it is estimated that 28% of the acute care visit and half of the hospital admissions emerge from the ED per Center of Disease and Control (2017). The authorization of Patient Protection and Affordable Care Act has shown the requirement for coordinating patient care voice in structuring the conveyance of social insurance (Rising et al., 2014). The clarifications for patients to come back to the ED, the plausibility of future return, and the rehashed return can be inspected from the administrative information. Some basic variables have been related with high rates of readmission of patients to the ED. They incorporate low follow up care and language boundary that bars patients from understanding the discharge guidelines. Other variables include old age, non-ambulatory status, and absence of family support. Background and Significance of Problem to Health Care/Nursing Return visits to the emergency department is a significant issue that several the Four Corner facility faces on a regular basis. These visits are not only cumbersome to the healthcare personnel, but also an important indicator of the quality of care. Hospital emergency departments (ED) constantly face the issue of restricted assets, high rates of patient admissions, aging populace, and deficiency of human services suppliers. Most EDs have gotten amazingly overcrowded. They are described by long holding up time that contributes negatively to the patients' outcomes. Patients returning to the emergency department have medical issues that have either failed to go away or improve or have gotten worse. Being an important metric to measure the quality of healthcare, the problem of unscheduled return visits to the emergency department is very important 2 Introduction to the Problem to healthcare or nursing since it provides the healthcare personnel with essential information regarding their performance or health output. A reduction in the rate of return visits to the ED is a marker of high-quality care, while an increase in the rate signifies poor healthcare performance and poor patient outcomes. Needs Assessment The daily number or volume of patient received in the Four Corner ED is 72-98, with 35% of these patients returning back to the ED because they did not have instructions for follow up, diagnoses explained, or test results given so they can provide to their primary care provider which has cause the PCP to referred the patient back to ED for further treatments. From that 35%, 12% end up being admitted due to their failure to complete treatment and to the lack of instructions in care after they had been discharged. There are several information gaps which occur due to the unavailability of patient information that were previously collected by a physician. Information gaps were present in around one-third of the visits to the emergency department. These gaps therefore meant that the physicians were not able to provide high quality care to the patients upon their first visit, increasing the chances of an unscheduled return visit to the emergency department (Hayward et al., 2018). Return visits to the ED is presently a metric of the adequacy of Emergency Department discharge activities. The short returns to the Emergency Department intently gets checked. This metric additionally mirrors the emergency care quality, particularly in situations where patients need hospitalization in their return to the ED. Nonetheless, there are issues to embracing return visits as proportions of value since it is unsure and connected with unpredictable results. ED offers care for a blend of the patient populace. A considerable lot of the patients get released home after 3 Introduction to the Problem treatment without legitimate training or directions. This analysis distinguished the issue in relation with the adult population in Four Corner ED. This investigation recognizes the gap that is to address the challenges that address the difficulties related with ED return visits. ED doctors must realize how to adjust expected hospitalization benefits against costs related with hospital stay and clinical vulnerability when settling on choices concerning patient hospitalization. Target Population/Community The Florida state is populous, which makes it an ideal spot to create and execute the intervention. ED information in this state is robust, and it is anything but difficult to follow return visits. The study population is adults in the state of Florida at Four Corner ED. They have differing social foundations, which are primarily dictated by race. Among the social or cultural perspectives that prevail in the American culture can be ordered into whites, African Americans, Hispanic, Asians, Native Americans, and individuals with a mix of two races. The way of life of the objective populace impacts their wellbeing, convictions about ailments and demise, ways of life as well as health advancement. The psychosocial measurements can be ordered into three. Restorative measurements identify with the sort of treatment, the impression of misery, and the clinical course. Mental variables spread the interruption of life objectives and the capability of modifying life plans utilizing coping strategies and emotional stability. The social variables contain the accessibility of help from close partners, for example, companions, family, and colleagues. The ecological elements for the target population are critical in impacting the nature of their wellbeing and characterizing the fundamental preventive measures. It is evaluated that 23% of all deaths in the world, just as 26% of deaths in kids under the age of 5, are contributed by natural factors that can be prevented (Healthy People 2020, 2019). A portion of the elements that 4 Introduction to the Problem effect the target population incorporate environmental change, exposure to toxins in food, water, air and soil, the contamination of their habitats, and occupational dangers. The estimated demographic descriptors of the population are 49.1% male and 50.9% female and a median age of 35 for both genders. The population has an average family size of 3.14. The health literacy of the target population varies significantly according to race. For example, 14% of the whites are proficiency in health literacy; the rate literacy rate for Hispanics is 4%, with that of the African American being only 2% (Rikard et al., 2016). The intermediate literacy rate for the three races is 58%, 31%, and 41 %, respectively. The proficiency level implies that individuals can clearly read, write, understand, and solve problems. The intermediate level suggests that people can experience a problem, such as solving problems. Health literacy has direct impacts on health outcomes. Literate people have better outcomes than illiterate ones. In 2016, the life expectancy of the target population was 78.8 (Rikard et al., 2016). Diabetes and stroke caused 21.3 and 37.6% of all deaths in this population. The adults that smoke cigarette makes 15.1% of the entire population. It is further estimated that 21.8% of the people visit the emergency room at least once a year. Project Purpose/Goal The purpose of this project is to enable the implementation of a clinical intervention to ensure a reduction in the unscheduled return visits to the emergency department. The proposed intervention is to use the skill of medical attendants in limiting congestion in the ED. These experts are at a perfect situation of reducing the crowding since they are in direct contact with patients. They, subsequently, have specific errands, which are the main drivers of overcrowding. The issue of the patients to comprehend release guidelines can be tended to effectively by medical attendants 5 Introduction to the Problem (Sayah et al., 2014). They handle all the vital techniques of guaranteeing that patients are released from the hospitals, which incorporates all the desk work that should be shown to the patients, their parents, or relatives. Nurses can grasp this opportunity to clarify in detail every one of the inquiries that the patients of guardians pose and, in any event,, asking them questions to guarantee that they understand the data they are given in detail. They can also step up to the plate by ensuring the transportation of the patients from the ED to their destinations, particularly when utilizing the ambulatory services. Nurses are in a better position to partake in clarifying the concerns of the patients as well as their diseases. This intervention can guarantee that patients stick to every one of the mandates of the directives of the care providers to maintain a strategic distance from occurrences arising from wrong medication. It ought to be fortified with legitimate ED training on patient management to prevent future returns. Intensive training can concentrate on improving the role of nurses and incorporating patient engagement. The efforts can guarantee that patients don't go to the ED again and, thus, reducing congestion. Concepts and Definitions Used in The Project Some of the main concepts of this project include the problem, which is unscheduled return visits to the emergency department, clinical interventions for the problem, DNP essentials, and advanced nursing practice. The clinical interventions to the problem of unscheduled return visits to the emergency department entail the utilization of the expertise of nurses in minimizing overcrowding in the ED. Nurses are the ideal group of healthcare personnel to reduce congestion in the emergency department because they have a direct connection or interaction with the patients. The DNP Essentials detail all the curricular elements required by DNP programs. Published by the AACN, they address the complex needs that apply to the modern healthcare system. Advanced 6 Introduction to the Problem nursing practice refers to a level of nursing practice which applies the use of experience, comprehensive skills, and knowledge in nursing care. Relationship of Project to Advanced Nursing Practice This project has a close connection with Advanced Nursing Practice in that it provides nurses with an opportunity to perform their duties regarding patient discharge and patient care. Nurses assume a key role in transforming care. They can offer nitty gritty clarifications concerning patient discharge to the patients. It will involve the factors that will emerge while the patient will be at home, and how to move toward circumstances that may force them to return to the ED (Rafnsson & Gunnarsdottir, 2010). This will help keep the patients from heading off to the ED once more. Another transient arrangement includes the doctors examining itemized data about the diseases affecting their patients. The doctors can likewise appropriately address worries that their patients may need to lessen their vulnerability. Over the long haul, the doctors and attendants ought to guarantee they make an ED-based care program that will integrate the care teams in the ED. The program should offer more trainings on taking care of patients at the ED including the parts of release to prevent the return cases (Rushforth, 2015). Intensive training should point towards upgrading the nurses and doctor roles that incorporates patient engagement. Developing a discharge checklist that when patients are going to be released from the ED they can check out and sign affirming that providers examined what is on the agenda with the patients before they leave the ED. Doctors can fill in as a contact to different partners who practice by helping them discover the patients fittingly. Doctors ought to likewise work intimately with distinguished drug specialists associated to the hospital, to offer medication counselling. This will cultivate patient selfmanagement and diminish vulnerability from patients (Schrader et al., 2019). 7 Introduction to the Problem The DNP Essential Aligned with The Project The project that I’m working on is supported by the essentials I, II and III. Essential I is the scientific underpinnings of this education which reflect the complexity of practice at the doctoral level and the rich heritage that is the conceptual foundation of nursing (AACN, 2006). The educational part of this project will assist healthcare providers to understand the patterning of human behavior in interaction with the environment in normal life events and critical life situations after being discharge from the ED. This will help improve science discipline by understanding the nature and significance of health and health care delivery phenomena. This essential also maintains that the extensive understanding of the nursing theory ensures that advanced nursing practice is built upon a solid foundation. Graduates can therefore integrate nursing practice with organizational or analytical sciences. These science-based concepts can therefore be used to improve the quality of healthcare. Essential II is the organizational and systems leadership to improve quality and systems thinking meaning that doctoral level knowledge and skills in these areas are consistent with nursing and health care goals to eliminate health disparities and to promote patient safety and excellence in practice (AACN, 2006). This essential helps in transforming research into practice. The project is based on quality improvement by making changes to current discharge policies by providing the best practice to discharge a patient. This will improve patient outcomes after being out of the ED and prevent them from returning because they didn’t understand discharge/after care instructions. Essential III states scholarship and research are the hallmarks of doctoral education (AACN, 2006). This essential mainly focuses on the complex issues that face modern health. It further focuses on the medical dilemmas that physicians face in patient care, as well as shaping 8 Introduction to the Problem the evidence-based initiatives in the agenda of healthcare. The project uses analytic methods to critically appraise existing policies and other evidence to determine and implement the best practice to discharge a patient from the ED. Project Alignment with Practice Site Mission and Goals The practice site for this project is a standalone emergency department in Polk County in the state of Florida. Its mission and some of its goals are closely aligned with the project objectives. With regard to this project, the main missions and goals of the practice site include providing high quality care to the patients and ensuring that they don’t make unscheduled return visits to the emergency department. Another goal is ensuring safe transitions of care, which is essential in promoting better patient experiences, reducing costs, and enhancing the quality of outcomes. Unscheduled return visits to the emergency department reflects inadequate follow-up procedures or discharge practices. The goal of the project site is to eliminate such poor indicators of poorquality patient care and ensure that the facility enhances its provision of high quality patient care. Key Stakeholders The key stakeholders in this project are the physicians, nurses, home care providers, managers, and prehospital care personnel, as well as the insurance companies who pay for the patients’ medical care. The emergency department stakeholders primarily focus on the several indicators that that focus mainly on their capacity to provide quality care. For emergency departments to effectively respond to patient care needs, the stakeholders must step in to ensure that the current environment of health care delivery, enabling the ED to adjust to changing models of care delivery; hence creating a controlled process that enhances the achievement of the goals and efficiencies of the healthcare facility. 9 Introduction to the Problem Benefit of Project to Practice Clinical Area The major benefits of this project to clinical practice is that it ensures the improvement of the quality of patient care, discharge process and follow-up care, as well as significantly reducing the overall cost of patient care. According to a study published in JAMA by Dr. Sabbatini and colleagues, it was determined that patients who return to the emergency department for further treatment have longer lengths of stay and increased costs during the repeat hospital admissions compared to those who do not return to the emergency department (Lee et al., 2015). A greater understanding of the essentials of this project will therefore be beneficial to physicians, nurses and other healthcare practitioners and improve their clinical practice; hence enhancing the overall patient care and outcomes, preventing unscheduled return visits to the emergency room. Cost/Benefit Analysis Return admissions in the emergency department often fail to adequately capture the deficits in the healthcare quality delivered during the first visit to the emergency department. The current efforts to provide the patients with quality care in the value-driven healthcare system has significant policy implications. The frequent changes in healthcare financing therefore give rise to certain policies which often encourage unnecessary hospitalizations which then encourage return admissions to the emergency department and hence increasing costs of healthcare. Appropriate measures should therefore be chosen by the healthcare providers to identify the quality of ED care and ensure that hospitals and physicians are incentivized to benefit the patients while also preventing the unwanted or unintended consequences (Soh et al., 2019). Scope of the Project 10 Introduction to the Problem This project covers not only the causes and implications of unscheduled return visits to the emergency room, but also its effects on the quality of health or patient outcomes. The US and the worldwide healthcare framework have been encountering a fast increment in the demand for ED. This has been resulting in the congestion of these rooms. Various studies have affirmed that between 2001 and 2008 ED returns were extensively high, and over half of the patients recorded multiple visits every year (Ericksen & Kocher, 2019). Out of these patients, over 1% had visited the ED in more than five times and added up to 18% of the considerable number of visits. The Centers for Disease Control evaluates that the US medicinal services framework records 145.6 million ED visits and return visits of at least 12.6 million every year (2017). In 2014, about 5.7% of the ED visits included patients that had been admitted before over the last three days on the grounds that the patients didn't comprehend the release directions (CDC, 2017). Moreover, this project covers the clinical interventions that would be necessary for reducing the rate of unscheduled return visits to the emergency department, and their implementation. The implementation strategy will entail the training of healthcare physicians on the fitting ways for releasing patients. It will likewise incorporate learning the discharge agenda that will be given to patients at the hour of their release, and which they need to check the imprint boxes of what they understand. They at that point need to sign after understanding and afterward come back to the medical caretaker after the training session. The expected outcome and evaluation strategy will be controlled by the degree to which the patients understand the instructions. The effectiveness of this intervention will be showed in the improvement of service delivery in the ED. The technique is required to diminish the congestion at the ED and improve patient outcomes. 11 Introduction to the Problem References American Association of Colleges of Nursing (AACN). (2006). DNP essentials. Retrieved from https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf 12 Introduction to the Problem Centers for Disease Control and Prevention. (2017). Emergency department visits. Retrieved from https://www.cdc.gov/nchs/fastats/emergency-department.htm Ericksen, G. M., & Kocher, K. (2019, April 12). Trends in Emergency Department Use by Rural and Urban Populations in the United States. Retrieved from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730472 Hayward, J., Hagtvedt, R., Ma, W., Vester, M., Gauri, A., & Holroyd, B. R. (2018). P068: Predictors of admission in unscheduled return visits to the emergency department. CJEM, 20(S1), S81-S81. doi:10.1017/cem.2018.266 Healthy People 2020. (2019). Environmental health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health Lee, S. H., Kim, K., Kim, H., Jeong, J. H., Kang, C., Rhee, J. E., … Hwang, S. S. (2015). Effect of multifaceted interventions on reducing return visits within 72 h after non-traumatic emergency department visits. Emergency Medicine Australasia, 27(5), 431-439. doi:10.1111/1742-6723.12457 Rafnsson, V., & Gunnarsdottir, O. (2010). 177: Return Visits, Hospitalization and Mortality After Uncompleted Initial Visit to the Emergency Department: A Prospective Study. Annals of Emergency Medicine, 56(3), S59. doi:10.1016/j.annemergmed.2010.06.224 Rikard, R. V., Thompson, M. S., & Beauchamp, A. (2016). Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022195/ 13 Introduction to the Problem Rising, K. L., Padrez, K. A., O’Brien, M., Hollander, J. E., Carr, B. G., & Shea, J. A. (2015). Return Visits to the Emergency Department: The Patient Perspective. Annals of Emergency Medicine, 65(4), 377-386.e3. doi:10.1016/j.annemergmed.2014.07.015 Rushforth, H. (2015). Advanced Nursing Practice: The Theoretical Context and Evidence Base. Advanced Nursing Practice, 21-49. doi:10.1007/978-0-230-37812-4_2 Sayah, A., Rogers, L., Devarajan, K., Rocker, K. L., & Lobon, F. L. (2014). Minimizing ED Waiting Times and Improving Patient Flow and Experience of Care. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009311/ Schrader, C. D., Robinson, R. D., Blair, S., Shaikh, S., Ho, A. F., D’Etienne, J. P., … Wang, H. (2019). Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study. BMC Health Services Research, 19(1). doi:10.1186/s12913-0194300-1 Soh, Lin, Pan, Ho, Mahadevan, Chua, & Kuan. (2019). Risk Factors for Emergency Department Unscheduled Return Visits. Medicina, 55(8), 457. doi:10.3390/medicina55080457 Running Head: TARGET POPULATION Implementation Plan 1 TARGET POPULATION 2 Identifying a Target Population Hospital emergency departments (ED) continuously face the problem of limited resources, increased patient presentation, aging population, and shortage of healthcare providers. Most EDs have, become among the most overcrowded sections of any healthcare facility. They are characterized by long waiting time that contributes negatively to the patients' outcome as well as low family experiences. However, ideal nursing interventions can play a central role in preventing the overcrowding of the ED. Problem Statement Although hospitals have been striving to cut the cost, this goal has not been satisfactorily addressed because of the challenge of patients returning to emergency departments. Most hospitals in the state of Florida have been focusing on reducing 30-day readmission with several initiatives and interventions (CDC, 2017). In Florida, it is estimated that 28% of the acute care visit and 50% of the hospital admissions arise from ED per Center of Disease and Control (2017). The enactment of Patient Protection and Affordable Care Act and has demonstrated the need for integrating patient care voice in designing the delivery of healthcare (Rising et al., 2014). The explanations for patients to return to the ED, the possibility of future return, and the repeated return can be examined from the administrative data. Some common factors have been associated with high rates of readmission of patients to ED. They include low follow up care and language barrier that limits patients from understanding the discharge instructions. Other factors can be old age, no ambulatory status, and lack of family support. Proposed Clinical Intervention TARGET POPULATION 3 The proposed intervention is to utilize the expertise of nurses in minimizing overcrowding in the ED. These professionals are at an ideal position of reducing the congestion because they are in direct contact with patients. They, therefore, have specialized tasks, which are the root causes of overcrowding. The problem of the patients to understand discharge instructions can be addressed adequately by nurses (Sayah et al., 2014). They handle all the necessary procedures of ensuring that patients are discharged from the hospital, which includes all the paperwork that needs to be illustrated to the patients, their caregivers, or family members. Nurses can take this opportunity to explain in detail all the questions that the patients of caregivers ask and even asking them questions to ensure that they understand the provided information in detail. They can also take the initiative of confirming the transportation of the patients from the ED to their destination, especially when using the ambulatory services. Nurses are in better positions of discussing in detail all the concerns of the patients as well as their illnesses. This intervention can ensure that patients adhere to all the directives of the care providers to avoid instances such as wrong medication. It should be reinforced with proper ED training on the management of patients to avert future returns. Intensive training can focus on enhancing the role of nurses and integrating patient engagement. The effort can ensure that patients do not go to the ED again and, consequently, reducing overcrowding. The contribution of nurses in the ED can also be manifested in developing discharge checklists before releasing patients from the hospital. This can ensure that all the expectations and requirements are fully addressed, and the patients are cleared. Precise follow-up should be deployed to ensure that patients are faring as expected and that they are not experiencing challenges with medications. With the advancement in modern healthcare, technologies like telemedicine can be used to maintain the connections between patients and nurses. These TARGET POPULATION 4 approaches can promote contact between the two parties and ensure that patients can reach the nurses without necessarily visiting the ED. The long-term intervention of nurses in minimizing the problem of overcrowding should focus on creating an ED-based care program that incorporates the care teams in ED management. The approach can also be in the form of training on a range of factors. They include the prevention of return cases. Nurses have a role of fostering evidence-based practice that can be instrumental in mitigating the problems of overcrowding in ED (Sayah et al., 2014). Most nursing concepts are based on training and evidence, which implies that the professional can design evidence-based practices to explore the problem from a scientific perspective. Such an approach will allow the nurses to shift from the traditional paradigm of clinical practice in ED to clinical expertise that is founded on scientific evidence, values, and preferences of patients. Analysis of the Target Population The study population is adults in the state of Florida. They have varying cultural backgrounds, which are mainly determined by race. Among the cultural aspects that prevail in American society can be categorized into whites, African American, Hispanic, Asians, Native Americans, and people with a combination of two races. The culture of the target population impacts their health, beliefs about diseases and death, lifestyles as well as health promotion. The psychosocial dimensions include can be categorized into three. Medical dimensions relate to the type of treatment, the perception of suffering, and the clinical course. Psychological factors cover the disruption of life goals and the potential of adjusting life plans using coping strategies and emotional stability. The social factors comprise the availability of support from close associates such as friends, family, and co-workers. TARGET POPULATION 5 The environmental factors for the target population are significant in influencing the quality of their health and defining the necessary preventive measures. It is estimated that 23% of all deaths in the world, as well as 26% of deaths in children below the age of 5, are contributed by environmental factors that can be prevented (Healthy People 2020, 2019). Some of the factors that impact the target population include climate change, exposure to toxins in food, water, air and soil, the contamination of their habitats, and occupational dangers. The estimated demographic descriptors of the population are 49.1% male and 50.9% female and a median age of 35 for both genders. The population has an average family size of 3.14. The health literacy of the target population varies significantly according to race. For example, 14% of the whites are proficiency in health literacy; the rate literacy rate for Hispanics is 4%, with that of the African American being only 2% (Rikard et al., 2016). The intermediate literacy rate for the three races is 58%, 31%, and 41 %, respectively. The proficiency level implies that individuals can clear read, write, understand, and solve problems. The intermediate level suggests that people can experience a problem, such as solving problems. Health literacy has direct impacts on health outcomes. Literate people have better outcomes than illiterate ones. In 2016, the life expectancy of the target population was 78.8 (Rikard et al., 2016). Diabetes and stroke caused 21.3 and 37.6% of all deaths in this population. The adults that smoke cigarette makes 15.1% of the entire population. It is further estimated that 21.8% of the people visit the emergency room at least once a year. Literature Support and the Clinical Problem The US and the global healthcare system have been experiencing a rapid increase in the demand for ED. This has been resulting in overcrowding of these rooms. Numerous studies have TARGET POPULATION 6 confirmed that between 2001 and 2008 ED returns were considerably high, and more than 50% of the patients recorded multiple visits each year (Ericksen & Kocher, 2019). Out of these patients, more than 1% had visited the ED more than five times and amounted to 18% of all the visits. The Centers for Disease Control estimates that the US healthcare system records 145.6 million ED visits and return visits of at least 12.6 million each year (2017). In 2014, about 5.7% of the ED visits involved patients that had been admitted before in the last three days just because the patients did not understand the discharge instructions (CDC, 2017). Strategy for Implementation of the Clinical Interventions The implementation strategy will be a classroom presentation and training of the appropriate ways for discharging patients. It will also include learning the discharge checklist that will be provided to patients at the time of their discharge, and which they have to check the mark boxes of what they understood. They then need to sign upon understanding and then return to the nurse after the education session. The expected outcome and evaluation strategy will be determined by the extent to which the patients understand the instructions. The effectiveness of this intervention will be manifested in the improvement of service delivery in the ED. The strategy is expected to reduce the overcrowding at the ED and improvement of the patient outcome. TARGET POPULATION 7 References Centers for Disease Control and Prevention. (2017). Emergency department visits. Retrieved from https://www.cdc.gov/nchs/fastats/emergency-department.htm Ericksen, G, M & Kocher, K. (2019). Trends in emergency department use by rural and urban populations in the United State. Retrieved from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730472 Healthy People 2020. (2019). Environmental health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health Rikard, V. R, Thompson, S. M, McKinney, J & Beauchamp, A. (2016). Examining health literacy disparities in the United State: A third look at the National Assessment of Adult Literacy (NAAL). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022195/ Rising, L. k, Padrez, A, B’Brien, M, Hollander. E. J Carr, G. B & Shea, A. J. (2014). Return visits to the emergency department: The patient perspective. Retrieved from http://unmhospitalist.pbworks.com/w/file/fetch/86493307/PIIS0196064414006222.pdf Sayah, A, Rogers, L, Devarajan, K, Rocker, K. L & Lobon, F, L. (2014). Minimizing ED waiting times and improving patient flow and experience of care. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009311/ DN733 Unit 6 Assignment: Policy Issue Analysis Worksheet Part I Analysis Criteria Name of person completing the analysis; sphere of government Is their potential bias? Explain your response. What is the issue that requires a policy solution? Context: Add evidence for the following perspectives: Social Economic Ethical Political Legal Environmental Cultural Costs Issue Analysis Part II Who are the Stakeholders in this policy issue? What is their ‘stake”? What is their value orientation? What are the health risk(s) addressed by the policy issue? Response How would the policy impact these risks? Use evidence. Specify the policy consequences, both intended and unintended, to the best of your ability. Issue Analysis Part III Specify 2-3 policy options (include ‘do nothing’ options – what happens if things continue as currently happening). Rationale for policy recommendations Identify criteria to evaluate policy options – enter on scorecard. Put each policy option in the Scorecard to rate your policy and its alternative Policy Options Scorecard Identify your policy and reasonable options including a "Do Nothing" option. Use this scorecard to rate your policy and the policy options. You can add criteria that you think are appropriate to your particular issue. Code your responses by using pluses and minuses. Code: ++ strongly positive, + positive, -- strongly negative, - negative Criteria: Evaluate your policy on each of these criteria Effectiveness Policy Policy Option # 1 Policy Option # 2 Policy Option # 3 Protection of rights Costs Administrative feasibility Fairness Evidence-based practice Environmental effects Power Cultural considerations Final Policy Problem Statement: Recommended Policy Solution--Identify which of the policy alternatives is the best solution-give rationale. Running Head: HEALTH CARE POLICY ISSUE ANALYSIS 1 Potential bias: Millions of patients visit emergency departments yearly for different illness or injuries. Indeed, the hospitals are making haste always to ensure that every minute is spent constructively and cost-saving; problems of return visits to the ED have been rampant but ideally not addressed (Cerlinskaite et al., 2020). Poor compliance, the return of patients to ED within 72 hours or more, and inadequate understanding has significant implications for patients like continuous and progression of the illness (Cerlinskaite et al., 2020). Improving the discharge process is very vital for preparations for any misfortune event with patients. Patients in the public health department are the most affected since they are left displaced, deprived of shelter, food, and other care services that require to be offered (Cerlinskaite et al., 2020). Providing a highquality discharge process, it initiates the preparations for patients to return home and can properly manage their recovery. This is not the case for the state of Florida, since the estimation gives that almost a third of acute care visits and half of the admission in the hospital come from emergency departments per CDC (Florida Department of Health, 2013). The probability of patients returning to the ED can be tested for future prospective and inspected from the administrative information (Cerlinskaite et al., 2020). A deep insight into the problem-Return visit to the emergency department is one of the biggest problems most facilities face across time according to Hoek, Amber E; Anker, Susanne C P; van Beeck, Ed F; Burdorf, Alex; Rood, Pleunie P M; Haagsma, Juanita A, (2019). They are indicators of the quality of care given to patients by doctors. They majorly occur due to frequent emergency medical services, poor patients' understanding of the discharge protocol, poor patients’ adherence to following the doctors' medical prescription, poor patients’ adherence to follow up the specialist, and even death occurrences following ED visits (Chen Y, Shen Y, Zhu Y, et al., 2020). These have become cumbersome and have led to congestion in emergency HEALTH CARE POLICY ISSUE ANALYSIS 2 departments. There is a great need for the reduction of cases of return visits. It indicates proper medical servicing (Ross et al., 2020). The need to improve discharge practices in the emergency department to prevent return visits is one fundamental role of all medical practitioners. It needs all healthcare providers to play their part in ensuring that all requirements are met. Clinical care, efficient process of discharge, prescriptions received from doctors to the patients are examined to identify the primary cause of return visits to the emergency departments (Campbell & Ditkoff, 2020). One of the primary reasons which have not been deeply looked into is the quality of care given in the emergency room. The provision of quality healthcare is an international mandate (Chen Y, Shen Y, Zhu Y, et al., 2020). Disorders increases at a faster rate. Some risk factors have been associated with poor health care, which translates to return visits. They include the following: lack of appropriate insurance facilities to patients, low income, and lack of primary care providers, race and ethnicity, and poor understanding of health illiteracy. Material pieces of evidence of causes of revisit to ED- Those who dwell in unstable housing are at a higher risk of readmission. Housing welfare is also a risk factor to discharge failure in the emergency department (Sheha et al., 2019). Legal- many patients who lacked insurance covers were found to be likely to face discharge failure and inappropriate medical attention, which lead to readmission (Chen Y, Shen Y, Zhu Y, et al., 2020). Patients who had bullet injuries were found not to be given immediate treatment instead of sent for an abstract from police officers to prove legal rights which this particular case has been seen multiple times in trauma emergency departments. This worsened situations in the patient's wounds, thus increasing treatment cost, which further called for the doctor visit and emergency revisits (Ross et al., 2020). HEALTH CARE POLICY ISSUE ANALYSIS 3 Economic- patients in the low-income category receive low-grade medical services. They also faced risk for following up doctors hence fall in the trap of readmission. Patients with postpaid receipts or medical cards were likely to receive low quality medical care, which alleviates their sufferings, causing them to be readmitted (Sheha et al., 2019). Even though there are advances in medical diagnosis and treatment of most chronic diseases, there is still the existence of racial and ethnic considerations that, without a doubt, affect the quality of medical care. The medical institute, statement on the unequal treatment, mentions racism and ethnic differences exist in healthcare units and are worsening the outcomes and medical quality (Sheha et al., 2019). The influence of culture affects human beliefs and perceptions of healthcare. Some healthcare givers and patients exhibit varying cultures, some of which do not mingle. Differences in beliefs concerning disease cause, how pain and illness are felt, and approaches to medical promotion vary (Hoffmann M, Schwarz CM, Pregartner G, et al., 2019). Strict cultures have been found to come for emergency visits most often due to unnecessary assumptions towards health according to Hoek, Amber E; Anker, Susanne C P; van Beeck, Ed F; Burdorf, Alex; Rood, Pleunie P M; Haagsma, Juanita A, (2019). The hospital program for readmission reduction is an initiative that offers affordable care. It aims at reducing payouts to facilities of care that have very many patients’ readmissions. The program states readmission as repeated admissions, but only allows for an exception like heart failures, and pneumonia among others like multiple illnesses (Ross et al., 2020). There is a valid reason as to why patients need well-planned medical care and deep intervention on discharge protocol. Premature patients' discharge should be abolished entirely and disallowed by medical stakeholders. Economic Costs of readmission-recently, there has been a rising cost on HEALTH CARE POLICY ISSUE ANALYSIS 4 readmission of patients in the ED. This occurs when the healthcare unit that recently discharged patients is given a penalty if the patient returns within 30 days (Hoek, Amber E; Anker, Susanne C P; van Beeck, Ed F; Burdorf, Alex; Rood, Pleunie P M; Haagsma, Juanita A, 2019). Recently, Kaiser Health news provided an estimation of yearly totals, which is approximately $566 million dollars (Rau, 2020). Moreover, an essential study by the quality health agency, estimates the average readmission cost is about $13,800 for every patient who receives Medicare (Rau, 2020). The most critical metric for calculating the readmission rate is the only solution to hospitals' success. Medicare readmission cost can be compared between insured and uninsured patients. Readmission rates for severe myocardial infarction, pneumonia, and heart failure were studied against the operating revenues for every patient, margin of operation, and the expense of service per patient (Campbell & Ditkoff, 2020). With the fixed effect of hospital-level regression on 277 health centers' annual observation, the study indicates that AMI readmission rates reduction is as a result of increased revenues of operation and as the hospitals try to avoid unnecessary readmissions, costly treatments are involved (Campbell & Ditkoff, 2020). Besides, the readmission rates reduction relates to high operating expenses. How to improve discharge practices-All patients must be issued with health insurance policy coverage-that will, at some reasonable rate, improve medical quality and care. It will make hospital oration achieve a quick and easy way for caring for patients (Cerlinskaite et al., 2020). Ensuring focus on discharges that are within the doctors' control- doctors should ensure that they only discharge patients at reasonable rates and never to over compete with time. Avoiding physicians' discharge orders through batch-it is found to create a severe backlog. For the particular hospital, a solution to technology like carrying an iPad was one among the solution providers (Ross et al., 2020). Creating a standard work for the entire process is another option. HEALTH CARE POLICY ISSUE ANALYSIS 5 Another way is to develop a specialist who acts as a discharge nurse for the ED. One more way to get rid of readmission is to have monthly data review of a nurse manager (Ross et al., 2020). On the other hand, doctors have a better understanding of which patient population has the most significant risk of readmission which can help reduce readmission scenarios. The health administration can also indulge in incentive programs with payers by giving incentives to healthcare providers in the emergency departments to prevent unnecessary hospital admission according to Berkman N, Sheridan S, Donahue K, Halpern D, Crotty K. (2014). The emergency caretakers can also ensure scheduling patients a seven day follow up after discharge-research proves that patients who followed up doctors were less likely to get readmission (Chen Y, Shen Y, Zhu Y, et al., 2020). The health caregivers can also partner with home caregivers in promoting a robust home health care program-post discharge that can help in avoiding readmission cases as health care continues even at home. The officers in charge of the ED must give clear and sound communication concerning post-discharge instructions. These instructions may include the education of patients about their disease and making use of the tech back method. All these are policies that can be used to reduce a patient's readmission. Stakeholders' analysis The keystone stakeholders in this piece are the managers, prehospital care personnel, discharge nurses, home care providers, physicians, and insurance companies. The emergency department personnel only played a part in ensuring that they give quality medical attendance. These are the indicator of superficial care in hospitals. They effectively respond to the patient's needs, immediate response to acute conditions and are requested to step into action and give quality care (Campbell & Ditkoff, 2020). The hospital managers have a role to play in ensuring that's strict supervision is achieved; financial budgeting is done on time and with zero corruption. HEALTH CARE POLICY ISSUE ANALYSIS 6 They must also ensure that health caregivers follow hospital rules and regulations. Home care providers are also called upon to ensure that doctors' prescriptions are followed as ordered to minimize readmission (Campbell & Ditkoff, 2020). The insurance must provide efficient access to their clients when it comes to an emergency condition. The health coverage must be in line with hospitals regulation to give a smooth flow of patients. Patients with insurance cards are easily treated. To determine whether patients with dual coverage of Medicare suffer from the same readmission rate as regular patients, the examination indicated that overall, 9.42% of the patients that have double coverage were readmitted in 30 days compared against the 13.12 % of regular patients (Campbell & Ditkoff, 2020). The champions of this project are the insurance companies, hospital directors, managers, and medical practitioners themselves. The primary opponents of this project were the home caregivers and a few patients who say that insurance subscriptions are too expensive and not affordable for everyone according to Campbell & Ditkoff (2020). Health risks- Many risks factors put patients in a challenging position due to poor outcomes including ED revisits, poor compliances, pcp follow-ups, and poor comprehension of discharge instructions. Moreover, without the medical coverage, the dual coverage, a lot of risks are involved because the medical quality might be lower than expected. It is accessible to spend much on cash rather than on insurance coverage (Campbell & Ditkoff, 2020). Incomplete payment and discharge failures are susceptible to those that lack the hospital insurance funds. There is a great need to have hospital coverage. Insurance policy will ensure that patients are given quality medical attendance, payment of all hospital bills, and comfort to the patients with accord to subscription leading to help reduce hospital cues, loss of finances, quick and organized patients discharge, among other benefits (Bidari et al., 2019). HEALTH CARE POLICY ISSUE ANALYSIS 7 The scope of the project-examines the causes and effects of return visits to emergency departments. It further touches on the healthcare quality given to patients by doctors. The primary indicators of poor health quality are the lack of medical coverage for patients (Bidari et al., 2019). Policy option-it is on condition that if the medical coverage is met, then major solutions would be achieved. There is no option of not taking the medical insurance cover. It must now be a command for all health seekers to have health covers. Cost and benefit analysis-return admissions in the emergency department are usually limited in capturing healthcare quality given to patients at the first visit to the emergency department (Campbell & Ditkoff, 2020). Medical coverage occupies a better part that offers the patients the security of quality medical care. In as much as subscription may be costly, it is also cost saving (Campbell & Ditkoff, 2020). To patients who use insurance covers when seeking treatment in the emergency department, there is always smooth flow and immediate medical attendance. At long last, the patient saves a lot of money, and this becomes a win-win scenario. Pieces of evidence of the proposed solution are that dual Medicare eligibility is related to lower rates of 30- day readmission of patients according to Campbell & Ditkoff (2020). Although, proper medical intervention must need to be upheld by health care expatriates through service alignment and quality medical attention. Improvement of discharge can also be made to ensure no unscheduled readmission. Insurance coverage that ease access to custodial care have been found to offer the most excellent satisfaction in reducing burdens of readmission in the emergency department (Sheikh, H., Brezar, A., Dzwonek, A. et al., 2018). Suppose the government will not get into the issue of enforcing the implementation of insurance coverages, worse will come to worse, and no solution will be working. The government must undertake HEALTH CARE POLICY ISSUE ANALYSIS 8 strict supervision to healthcare emergency wings, a random checkup to monitor doctors and patients. The critical intervention to this policy is the government who has all power and authority. Universal health coverage requires an efficient health system that gives the whole population access to excellent quality services, health workers, medicines, and technologies (Bidari et al., 2019). The changes in emergency response require immediate interventions because change is inevitable; one needs not to think mush when implementing a change. Changes in medical quality affect the answer that helps save on unnecessary readmission costs (Campbell & Ditkoff, 2020). The government must provide a quick link to the insurance bodies for the insurance policy to be implemented. Enforceability must be done by the government, hospital stakeholders, and the insurance companies. It must be reinforced for quick implementation. It is a very cheap exercise, and with the help of the government, the activity will run smoothly. The timeline for the application I consider to be not more than five months.in five months, the exercise shall be over, and every citizen will have easy access to the medical world. The opposing stakeholders who were majorly few patients will be called upon for a seminar to discuss the benefits of the proper insurance policy (Bidari et al., 2019). Recommendations Some ways of ensuring that such policies are put to practice, there must be effective communication with individuals across different levels. Effective communication between doctors and patients concerning their disease and how to care for them, advise them to see the doctor regularly to prevent the resurrection of the disease symptoms (Samuels-Kalow ME, Stack AM, Porter SC., 2012). Communicating with nurses and doctors on discharge instructions, sufficient staffing of nurses during patient care. HEALTH CARE POLICY ISSUE ANALYSIS 9 Alignment of services through resource provision for continuity of care-enough resources that are required in conduction disease diagnosis, medicines, and other essential emergency tools should be in place and with easy access to the devices (Chen Y, Shen Y, Zhu Y, et al., 2020). Services offered to patients by doctors require being capable and worthy. Doctors need to be quality-driven, punctual, and show commitment on the way to their jobs. Efficient, clear discharge can also be done e.g., by the provision of test results, treatment, diagnosis, and follow up care. Doctors in the ED are must come to senses and realize that they are dealing with human life and need a lot of attention and response. Tests can be done to patients, analysis of the trial, diagnosis of the patients, and finally, proper treatment. Conclusion This project is in line with my DNP as is not only emphasizes on return visits cases but also touches on the quality of health care given to the emergency patients. It feels on how health care providers can apply the correction policies in the ED in approaching the return visits. It also tries to move on to the quality of health care. Most doctors and nurses in the ED are fond of assuming careless behaviors, which lead to poor diagnosis, poor medical attendance, and lack of checkup before discharge. For this reason, propose the health care department should employ professional personnel and skilled labor in evaluating such an issue. They must also conduct keen monitoring, as well as give incentives to healthcare providers to psyche them up. HEALTH CARE POLICY ISSUE ANALYSIS References Berkman N, Sheridan S, Donahue K, Halpern D, Crotty K. (2014). Low health literacy and health outcomes: an updated systematic review. Ann Intern Med;155(2):97–107. 10 HEALTH CARE POLICY ISSUE ANALYSIS 11 Bidari, A., Mosaddegh, R., Mohammadi, F., Rezaei, M., & Roboobiat, K. (2019). Evaluating the Causes of Readmission to Emergency Departments of Hospitals Affiliated with Iran University of Medical Sciences. Iranian Journal of Emergency Medicine, 6(1), 13. Campbell, D., & Ditkoff, J. (2020). Evaluating Hospital Readmissions Through the Perspective of the Returning Emergency Department Patient. Quality Management in Healthcare, 29(1), 15-19. Cerlinskaite, K., Mebazaa, A., Cinotti, R., Wussler, D. N., Gayat, E., Juknevicius, V., & Celutkiene, J. (2019). P785 Unplanned readmissions after discharge increases risk of death in acute dyspnoea patients: non-cardiac is as severe as cardiac causes. European Heart Journal, 40(Supplement_1), ehz747-0384. Chen Y, Shen Y, Zhu Y, et al., (2020) Patients need more than just verbal instructions upon discharge from the emergency department. Evidence-Based Nursing Published: 07 February 2020. doi:10.1136/ebnurs-2019-103208. Florida Department of Health, (2013). Discharge Planning Resource Guide Addendum, Section 381.0303 (e) F.S. Retrieve from: http://www.floridahealth.gov/programs-andservices/emergency-preparedness-and-response/disaster-response-resources/dischargeplanning/index.html. Hoek, Amber E; Anker, Susanne C P; van Beeck, Ed F; Burdorf, Alex; Rood, Pleunie P M; Haagsma, Juanita A, (2019). Patient Discharge Instructions in the Emergency Department and Their Effects on Comprehension and Recall of Discharge Instructions: A Systematic Review and Meta-analysis. Annals of Emergency Medicine. ISSN: 10976760. DOI10.1016/j.annemergmed.2019.06.008, Published by ELSEVIER HEALTH CARE POLICY ISSUE ANALYSIS 12 Hoffmann M, Schwarz CM, Pregartner G, et al., (2019). Attitudes of physicians towards target groups and content of the discharge summary: a cross-sectional analysis in Styria, Austria BMJ Open 2019;9:e034857. doi: 10.1136/bmjopen-2019-034857 Rau Jordan, (2020). Medicare Eases Readmission Penalties Against Safety-Net Hospitals. Kaiser Health News. Retrieve from: https://khn.org/news/medicare-eases-readmissionspenalties-against-safety-net-hospitals/ Ross, T. D., Dvorani, E., Saskin, R., Khoshbin, A., Atrey, A., & Ward, S. E. (2020). Temporal Trends and Predictors of Thirty-Day Readmissions and Emergency Department Visits Following Total Knee Arthroplasty in Ontario Between 2003 and 2016. The Journal of arthroplasty, 35(2), 364-370 Samuels-Kalow ME, Stack AM, Porter SC. (2012). Effective discharge communication in the emergency department. Ann Emerg Med;60(2):152-9. Sheha, E. D., Salzmann, S. N., Khormaee, S., Yang, J., Girardi, F. P., Cammisa, F. P., ... & Hughes, A. P. (2019). Patient Factors Affecting Emergency Department Utilization and Hospital Readmission Rates After Primary Anterior Cervical Discectomy and Fusion: A Review of 41,813 cases. Spine, 44(15), 1078-1086 Sheikh, H., Brezar, A., Dzwonek, A. et al. (2018) Patient understanding of discharge instructions in the emergency department: do different patients need different approaches? Int J Emerg Med 11, 5. https://doi.org/10.1186/s12245-018-0164-0 DN733 Unit 6 Assignment: Policy Issue Analysis Worksheet Part I Analysis Criteria Name of person completing the analysis; sphere of government Is their potential bias? Explain your response. What is the issue that requires a policy solution? Context: Add evidence for the following perspectives: Social Economic Ethical Political Legal Environmental Cultural Costs Issue Analysis Part II Who are the Stakeholders in this policy issue? What is their ‘stake”? What is their value orientation? What are the health risk(s) addressed by the policy issue? Response How would the policy impact these risks? Use evidence. Specify the policy consequences, both intended and unintended, to the best of your ability. Issue Analysis Part III Specify 2-3 policy options (include ‘do nothing’ options – what happens if things continue as currently happening). Rationale for policy recommendations Identify criteria to evaluate policy options – enter on scorecard. Put each policy option in the Scorecard to rate your policy and its alternative Policy Options Scorecard Identify your policy and reasonable options including a "Do Nothing" option. Use this scorecard to rate your policy and the policy options. You can add criteria that you think are appropriate to your particular issue. Code your responses by using pluses and minuses. Code: ++ strongly positive, + positive, -- strongly negative, - negative Criteria: Evaluate your policy on each of these criteria Effectiveness Policy Policy Option # 1 Policy Option # 2 Policy Option # 3 Protection of rights Costs Administrative feasibility Fairness Evidence-based practice Environmental effects Power Cultural considerations Final Policy Problem Statement: Recommended Policy Solution--Identify which of the policy alternatives is the best solution-give rationale.
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