NUR 7120 Module 6 Resource Acquisition Paper: A Business Case for a Transitional Care Nurse to Reduce Readmissions Example

Paying for Prevention: A Business Case for a Transitional Care Nurse

Student Name

M.S. in Nursing, Nursing Administration, Thomas Edison State University

NUR-7120: Nursing Administration: Resource Acquisition and Management

Mentor Name

Month Day, Year

Paying for Prevention: A Business Case for a Transitional Care Nurse

The Problem

Last year almost one in four of our heart failure discharges, 24 percent, ended in a readmission within 30 days, above the national average, and the hospital was assessed a penalty under the federal Hospital Readmissions Reduction Program that reduced its Medicare payments by about $410,000. Our telemetry unit discharges about 420 heart failure patients a year. Chart review showed that many readmitted patients had not filled their new prescriptions, did not understand daily weights or had no follow-up appointment within a week.

The Policy Context

Zuckerman et al. (2016) analyzed Medicare data before and after the Hospital Readmissions Reduction Program, which penalizes hospitals with higher than expected readmissions for targeted conditions, including heart failure. In 2007, 21.5 percent of patients with penalized conditions returned within 30 days; by 2015 the figure was 17.8 percent, with the steepest drop after the program was announced. Readmissions for other conditions declined as well. Observation stays rose during those years, yet hospitals where observation grew most did not show bigger readmission drops. The program gave hospitals a financial reason to invest in care after discharge.

Evidence for Nurse-Led Transitions

Naylor et al. (1999) randomly assigned 363 hospitalized patients aged 65 and older at high risk of poor outcomes to usual care or to a program where advanced practice nurses handled discharge planning and followed patients by home visits and phone calls for four weeks. By 24 weeks after discharge, patients in the intervention group were less likely to be readmitted, 20 percent compared with 37 percent, had fewer total readmissions and days in the hospital and incurred about half the total medical costs.

Coleman et al. (2006) randomly assigned 750 older patients to usual care or to coaching. In the coached group, a transition coach, often a nurse, met patients in the hospital, visited them at home and called them several times, teaching them to manage medications, recognize warning signs and prepare for follow-up visits. Coached patients had fewer rehospitalizations at 30, 90 and 180 days, and hospital costs were lower as well.

The Proposed Role

I proposed one full-time transitional care nurse for heart failure patients. The nurse would meet each patient before discharge, reconcile medications with the pharmacist, teach daily weights and warning signs using teach-back, confirm a follow-up appointment within seven days, visit high-risk patients at home within 72 hours and call all patients at days 2, 7 and 14.

Who Gets Home Visits

Home visits are the most expensive part of the role, so they will go to patients most likely to benefit. Patients will be scored before discharge on prior admissions in the past six months, living alone, polypharmacy, cognitive impairment and difficulty paying for medications. Those at highest risk receive a home visit within 72 hours; others receive the scheduled phone calls.

Working With Outpatient Partners

The nurse's success depends on partners outside the hospital. The cardiology clinic agreed to hold three appointment slots each week for patients discharged from our unit, the outpatient pharmacy agreed to deliver discharge prescriptions to the bedside and the home health agency will share visit notes. These agreements cost little but remove the most common gaps found in the chart review.

The Patient's Experience

For patients, the role means one person who knows them from the hospital bed to the kitchen table. In a short pilot of the teaching approach on our unit, patients who received teach-back on daily weights were more likely to bring a weight log to their first clinic visit, an early sign that the program changes behavior at home.

Costs

Salary and benefits for one registered nurse with transitional care experience total about $118,000 a year. Mileage, a tablet, scales for patients without one and training add about $14,000, for a total of $132,000.

Projected Savings

If the role lowers heart failure readmissions from 24 to 18 percent, a reduction smaller than in the trials, about 25 fewer readmissions would occur each year. With each heart failure readmission costing the hospital roughly $11,000, the hospital would avoid about $275,000 in costs it cannot fully recover, and a lower readmission rate would reduce or eliminate future penalties, which were $410,000 last year. Even counting only half these amounts, the role would pay for itself.

Risks and Alternatives

The main risks are that the program reduces readmissions less than expected or that the nurse's caseload exceeds capacity. I proposed limiting home visits to the highest-risk patients and reviewing results after six months. An alternative, a telephone-only program, would cost less but has weaker evidence. A third option, contracting the work to a home health agency, would cost more and give the hospital less control.

The Executive Summary

I presented the case to our nursing and finance executives as a two-page executive summary: the problem in numbers, the evidence, the costs, the conservative savings estimate, the risks and the measures. They approved a one-year pilot.

Measuring Results

We will track 30-day heart failure readmissions, follow-up visits within seven days, medication discrepancies found, patient-reported confidence in self-care and the hospital's penalty status.

Limits

The Naylor and Coleman trials enrolled older patients with various conditions, not only heart failure, and were conducted decades ago. Readmission costs vary by payer. The hospital and figures are invented.

Conclusion

Zuckerman and colleagues showed that federal penalties moved readmissions, Naylor and colleagues showed that advanced practice nurse discharge planning with home follow-up cut readmissions nearly in half and costs and Coleman and colleagues showed that coaching patients in self-management works. A transitional care nurse, justified by a conservative business case, is a new resource that can pay for itself while keeping patients home.

References

Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822

Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613-620. https://doi.org/10.1001/jama.281.7.613

Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, observation, and the Hospital Readmissions Reduction Program. New England Journal of Medicine, 374(16), 1543-1551. https://doi.org/10.1056/NEJMsa1513024