BSNU Capstone WGU D226-Proposal Change - Passed on the 1st try.
Comprehensive Healthcare Change Proposal
BSNU
WGU
D226
Rachel Crisman
College of Health Professions
Western Governors
University
D226: BSNU Capstone
Kelly Martin
September 24, 2024
, A1. Innovative Change
I would like to propose a position for a Transitional Care Nurse (TCN) at Major Health Partners
on the Adult Inpatient Unit patients who are considered at “high risk” for re-hospitalization
within 30 days after discharge. High risk patients would be determined by my hospital’s health
information system, Meditech. Meditech uses a risk scoring that looks at patient factors, such as
age, BMI, current number of medications and compliance history, chronic health conditions,
behavior and mental health history, number of ED visits, number of inpatient hospitalizations,
number of PCP visits in the last 12 months and what was the current admitting diagnosis. Patient
would be considered high risk for re-hospitalization if their risk score is 10 or higher. Answers
in each category listed would count toward the risk score.
The Transitional Care Nurse (TCN) would follow the patient throughout their hospital
stay and once they discharge they would follow the patient for 2 weeks after discharge. The
purpose of this role would be for the TCN to follow up on SDOH that may be barriers for the
patient upon discharge, provide community resources to found barriers, and provider discharge
instruction education or reinforcement upon discharge, and follow up on the patient once in the
home after discharge. The TCN will work to empower the patient to manage their health care
needs outside the hospital setting, as a result decreasing their risk of re-hospitalization.
A1a. Authorized Proposed Change
See attached verification form.
A1b. Organizational Sponsor Discussion
I discussed my proposal with my Team Lead Supervisor in Case Management, Alanna. I
introduced the proposal to her and discussed with her why I thought the TCN role was in
important addition to our case management team in lowering our re-hospitalization rate as well
as providing extra support to our high risk patients after discharge. She thought the idea of a
transitional care nurse could potentially help improve our hospital’s re-hospitalization rate. Our
discussion focused on what steps would need to be taken to obtain approval for the new role and
how we would determine success for the new role.
A1c. Proposed Changes
Alanna didn’t determine any needed changes were needed to my proposal. Alanna has
worked in the Case Management and Utilization Review for 3 years and for the last year she has
been our Team Lead for our Case Management department. Alanna sees the need to decrease our
re-hospitalizations rate through her role as a case manager team lead and Utilization Review
nurse. Alanna attends our hospital re-hospitalization meetings each month and discusses with
hospitalists, primary care providers, outpatient case managers and other hospital leadership to
determine how to improve re-hospitalization rates. When I presented this idea to her she was
excited and was hopeful we could get approval for this position. Alanna and I determined that
we wanted to include a patient survey in the measurements to determine success. We felt it was
important to not only to see a decreased number of re-hospitalizations, but to have patient
feedback whether the transitional care nurse was beneficial to their overall healthcare plan at
discharge.
A2. Data to Support the Need for Change
The average cost of re-hospitalization was $15,000 in 2018 as reported by the Agency
for Healthcare Research and Quality (AHRQ) (2018). The rising healthcare costs in the United
States has created a need for a different outlook for healthcare management. In October of 2012,
the Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP),
which allows the CMS to penalize hospitals with excessive readmission rates for targeted
Comprehensive Healthcare Change Proposal
BSNU
WGU
D226
Rachel Crisman
College of Health Professions
Western Governors
University
D226: BSNU Capstone
Kelly Martin
September 24, 2024
, A1. Innovative Change
I would like to propose a position for a Transitional Care Nurse (TCN) at Major Health Partners
on the Adult Inpatient Unit patients who are considered at “high risk” for re-hospitalization
within 30 days after discharge. High risk patients would be determined by my hospital’s health
information system, Meditech. Meditech uses a risk scoring that looks at patient factors, such as
age, BMI, current number of medications and compliance history, chronic health conditions,
behavior and mental health history, number of ED visits, number of inpatient hospitalizations,
number of PCP visits in the last 12 months and what was the current admitting diagnosis. Patient
would be considered high risk for re-hospitalization if their risk score is 10 or higher. Answers
in each category listed would count toward the risk score.
The Transitional Care Nurse (TCN) would follow the patient throughout their hospital
stay and once they discharge they would follow the patient for 2 weeks after discharge. The
purpose of this role would be for the TCN to follow up on SDOH that may be barriers for the
patient upon discharge, provide community resources to found barriers, and provider discharge
instruction education or reinforcement upon discharge, and follow up on the patient once in the
home after discharge. The TCN will work to empower the patient to manage their health care
needs outside the hospital setting, as a result decreasing their risk of re-hospitalization.
A1a. Authorized Proposed Change
See attached verification form.
A1b. Organizational Sponsor Discussion
I discussed my proposal with my Team Lead Supervisor in Case Management, Alanna. I
introduced the proposal to her and discussed with her why I thought the TCN role was in
important addition to our case management team in lowering our re-hospitalization rate as well
as providing extra support to our high risk patients after discharge. She thought the idea of a
transitional care nurse could potentially help improve our hospital’s re-hospitalization rate. Our
discussion focused on what steps would need to be taken to obtain approval for the new role and
how we would determine success for the new role.
A1c. Proposed Changes
Alanna didn’t determine any needed changes were needed to my proposal. Alanna has
worked in the Case Management and Utilization Review for 3 years and for the last year she has
been our Team Lead for our Case Management department. Alanna sees the need to decrease our
re-hospitalizations rate through her role as a case manager team lead and Utilization Review
nurse. Alanna attends our hospital re-hospitalization meetings each month and discusses with
hospitalists, primary care providers, outpatient case managers and other hospital leadership to
determine how to improve re-hospitalization rates. When I presented this idea to her she was
excited and was hopeful we could get approval for this position. Alanna and I determined that
we wanted to include a patient survey in the measurements to determine success. We felt it was
important to not only to see a decreased number of re-hospitalizations, but to have patient
feedback whether the transitional care nurse was beneficial to their overall healthcare plan at
discharge.
A2. Data to Support the Need for Change
The average cost of re-hospitalization was $15,000 in 2018 as reported by the Agency
for Healthcare Research and Quality (AHRQ) (2018). The rising healthcare costs in the United
States has created a need for a different outlook for healthcare management. In October of 2012,
the Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP),
which allows the CMS to penalize hospitals with excessive readmission rates for targeted
