Evidence-Based Practice Project- PICOT Paper
Evidence-based practices (EBP) are integral to conventional healthcare practice. EBP utilizes the best and latest scientific evidence to inform medical practice. Parry et al. (2021) note that systematic implementation of EBP elevates healthcare delivery and optimizes clinical outcomes. This paper describes a PICOT formatted question for a quality improvement process in healthcare.
PICOT Question
In adult patients at a community inpatient hospital (P), does implementation of transitions of care program involving discharge education, medication reconciliation, follow-up appointment assistance, and care coordination (I) compared to “usual care” practices (C), reduce 30-day readmission (O) rates over 6 months (T)?
Population Demographics and Health Concerns
The target population for the quality improvement plan is adults in community inpatient care. Best practices in managing adult patients under inpatient hospital care integrate disease prevention, best and high-quality care, and proper care coordination during the care continuum (Wachholz et al., 2021). Notwithstanding, care coordination during care continuity and transition to home-based care, especially for patients with chronic illnesses, presents considerable challenges to care organizations.
A health concern during care continuity for patients transitioning from hospital-based care is the high hospital readmission rates within a month of discharge. These readmissions are thought to have a multivariate etiology. Defects in the discharge processes, poor care coordination during care transition, lack of post-discharge education, and disease complications have been implicated in significant hospital readmission rates and consequent escalation in the cost of healthcare (Wang et al., 2022). Addressing these concerns may provide the groundwork for quality improvement during the care transition for patients under community inpatient care.
Evidence-based Intervention
Care transition programs are EBP that can help address high hospital readmission rates. These programs provide a systematic framework for handing over care to the patients and the patient’s families. They emphasize quality and safety safeguards by enhancing the patients’ accountability to the care processes. Diverse care transition models can be leveraged to enhance care continuity. The transitional care model, the Care transitional intervention model, and the bridge program are some care transition models recommended by the Aging and Disability Resources Center (ADRC). These models integrate diverse aspects of chronic care, such as social workers’ involvement, elaborate surveillance and patient monitoring systems, and available health information technologies to maintain contact between caregivers and patients for as long as possible.
Comparison of the Intervention to Previous Practice
There is a divergence in how diverse healthcare systems manage care transition processes. In the traditional care approaches, care transition is fragmented, with care organizations making little effort towards strengthening their communication channels with their patients after discharge. Apparent fragmentation in care processes during care continuity and transition to home-based care has been linked with increased utilization of the emergency departments and subsequent elevation of hospital costs. The use of care transition programs produces a paradigm shift that enhances the engagement of care organizations and care providers in patient wellness after discharge. They establish an open channel of communication between caregivers and patients and have been shown to reduce hospital readmission after discharge (Fønss Rasmussen et al., 2021). This warrants their integration into conventional care.
Expected Outcome
Integration of care transitional programs to conventional patient management and care transition processes is likely to reduce hospital readmission rates. These programs ensure that defects during discharge, such as medical and medication errors, are adequately addressed before discharging the patients. Additionally, care transition programs enhance care coordination during the care continuum and transition to home-based care. Care transition programs are also likely to expand the patients’ knowledge of their disease process and management interventions, thus bolstering their self-care skills and capabilities (Fønss Rasmussen et al., 2021). Overall, care transitional programs will reduce patients’ utilization of emergency department services post-discharge and subsequently eliminate the need for hospital readmission.
Time for Implementation Evaluation
Implementing and evaluating a care transitional program for patients transitioning to home-based care fetches significant time considerations. In this case, the process is expected to take at least six months. Patients being discharged from inpatient care will be monitored for events requiring the use of the emergency department. Fønss Rasmussen et al. (2021) note that the majority of unplanned hospital readmissions occur within 30 days of hospital discharge but may be prolonged in the event of disease complications. It is necessary that the patients are monitored for a relatively lengthened span to establish their readmission potential.
How Nursing Science, Social Determinants of Health, and Epidemiologic, Genomic, and Genetic Data are Applied or Synthesized to Support Population Health Management for the Selected Population
Nursing science advocates for EBP in patient management and care transition processes. As a standard of nursing practice, caregivers are required to utilize best practices informed by research to address diverse patients’ concerns. Applying an EBP in care transition is thus aligned with the best principles of nursing practice. Care transition programs are also in concert with the social determinants of health provisions on access to healthcare. These programs enhance access to healthcare by maintaining contact between healthcare professionals and caregivers. Epidemiologic, genetic, and genomic data help in discerning at-risk populations. Patients under inpatient care are at high risk for various adverse healthcare events.
Notably, EBP is integral to quality improvement in healthcare. EBP, such as care transitional programs, are effective in addressing apparent problems in healthcare, such as high hospital readmission rates. As evident above, these approaches elevate the quality of care during the care transition, warranting their integration into conventional care.
References
Fønss Rasmussen, L., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review. BMJ Open, 11(1). https://doi.org/10.1136/bmjopen-2020-040057
Parry, C., Johnston-Fleece, M., Johnson, M. C., Shifreen, A., & Clauser, S. B. (2021). Patient-centered approaches to Transitional Care Research and implementation. Medical Care, 59(Suppl 4). https://doi.org/10.1097/mlr.0000000000001593
Wachholz, L. F., Knihs, N. da, Sens, S., Paim, S. M., Magalhães, A. L., & Roza, B. de. (2021). Good practices in transitional care: Continuity of care for patients undergoing liver transplantation. Revista Brasileira de Enfermagem, 74(2). https://doi.org/10.1590/0034-7167-2020-0746
Wang, Y., Eldridge, N., Metersky, M. L., Rodrick, D., Faniel, C., Eckenrode, S., Mathew, J., Galusha, D. H., Tasimi, A., Ho, S.-Y., Jaser, L., Peterson, A., Normand, S.-L. T., & Krumholz, H. M. (2022). Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. JAMA Network Open, 5(5). https://doi.org/10.1001/
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Question 
Refer to the PICOT you developed for your evidence-based practice project proposal in the Evidence-Based Practice Project Proposal: PICOT assignment in Topic 3. If your PICOT requires revision, include those revisions in this assignment. You will use your PICOT paper for all subsequent assignments you develop as part of your evidence-based practice project proposal in this course and in NUR-590, during which you will synthesize all of the sections into a final written paper detailing your evidence-based practice project proposal.
Evidence-Based Practice Project- PICOT Paper
Write a 750-1,000-word paper that describes your PICOT. Include the following:
Describe the population’s demographics and health concerns.
Describe the proposed evidence-based intervention and explain how your proposed intervention incorporates health policies and goals that support healthcare equity for the population of focus.
Compare your intervention to previous practice or research.
Explain what the expected outcome is for the intervention.
Describe the time for implementing the intervention and evaluating the outcome.
Explain how nursing science, social determinants of health, and epidemiologic, genomic, and genetic data are applied or synthesized to support population health management for the selected population.
Create an appendix for your paper and attach the PICOT. Be sure to review feedback from your previous submission and revise your PICOT accordingly.