A1. Innovative Change The implementation of a designated Professional BSN or greater RN Transitional Care Patient Education Nurse in skilled nursing facilities is an innovative change that would provide increased specialized education and comprehensive discharge instructions to improve patient outcomes, decrease recurrent hospitalizations for those with chronic illness and create value by reducing expenses and unnecessary overutilization of resources. Patients are not being given quality instructions about their disease process, medication management, treatments and most important exacerbation prevention skills with the current discharge process. The discharge process is rushed and fragmented, preventing the patients from comprehending and retaining the information presented. The focus of this project is to implement a dedicated transitional care education nurse to provide an individualized education and discharge plan to reduce adverse events and preventable readmissions. Because most patients are discharged to skilled nursing facilities from acute care hospitals before going home, it is these facilities that carry the heaviest burden to ensure patients are well educated on their specific disease management. Several studies have been done and policies written including the Hospital Readmission Reduction Program of 2012 to help structure value-based programing and encourage hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions (Hosp. Readmission Reduction, n.d.). Although most agree that improvements in discharge planning are necessary to improve patient outcomes and that a valuebased approach is best, few propose any ideas on how to accomplish such a task. A1a. Authorized Proposed Change See attached Verification Form
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