Dana Lawson
NUR/598
April 27, 2015
Dr. Margaret Coluciello
Plans to Decide the Future of Your Solution This evidence-based practice method will be implemented as a proposed solution to decreasing heart failure (HF) readmission rates. Transitional care activities ensure health care continuity, reduce risk of poor health outcomes, and facilitate safe transfer between levels of care or health care settings (Naylor et al., 2011).
Methods and Specific Plans to Maintain a Successful Project Solution
Methods and Specific Plans to Extend a Successful Project Solution This proposal will be implemented as a pilot program between the Heart Hospital …show more content…
On the hospital side, a clinical nurse specialist on the cardiac unit and a program analyst will ensure that referrals are made to appropriate patients and discharge plans include the transitional care activities. On the home health side, the Norfolk branch team leader, clinical informaticist, and information technology data specialist will monitor program operations. This team will collaborate closely to ensure that program implementation is successful. If the program is not yielding the expected outcomes then a strengths, weaknesses, opportunities, and threats (SWOT) analysis will be performed. All barriers identified will be addressed in a timely manner and changes may be made to the initial plan to promote success. In addition, staff and patients will be surveyed to ascertain challenges not readily apparent to the implementation team. These surveys will be designed and conducted by the clinical education department for the hospital and home health agency. The timeframe for conducting patient surveys will occur within seven days of admission into the program and then every 60 days. Since patients will need to be reassessed every 60 days for continuation of home health services, it is feasible to conduct the transitional care program survey concurrently. The team reserves the right to conduct additional patient surveys if a patient is readmitted to the hospital at any time during program participation or opts out of the transitional care program. Staff at the hospital and home health agency will be surveyed 90 days from their training date on the transitional care program and then every six months. Results of these surveys will be shared with the project team implementation coordinators during the monthly team