NR 706 WEEK 4 PAPER Information Systems Translation Science Project Guidelines ALL SOLUTION FALL-2022 LATEST 100% CORRECT GUARANTEED GRADE A+

Introduction The hospital readmission rate in the post-acute care setting continues to be a major challenge leading to negative patient outcomes including but not limited to undernutrition, cognitive decline, falls, and up to death. In the United States, more than 16,000 skilled nursing facility continues to provide care to more than 1.35 million individuals annually who need different levels of care from skilled nursing and rehabilitation services to assistant with ADLs and IADLs or transition into long term care residents (Center for Medicare & Medicaid Services, 2019). While a great percentage of these patients receive long term care services, some receive short term rehabilitation services with the transition to their primary residence with home health care services or otherwise. One of the greatest challenges for post-acute care facilities both for patients and the facilities is the great readmission rates which expose patients to unnecessary hospital readmissions, negative health outcomes and delayed rehabilitation period and return to the regular state of health and functionality (CMS, 2019). Some of the issues associated with rehospitalization after patient have been discharged to post-acute care settings includes but limited to • Cognitive impairments • Sepsis • Increased falls • Feeding difficulties or decreased appetite • Death (CMS,2019). Practice problem and Question.Information Systems Translation Science Project Guidelines. 3 Being discharged from an acute care setting to skilled nursing facilities is associated with a 17.8% readmission rate compared to the 15.8% with home discharges. With over 35 million hospital discharges annually in the United States and unplanned readmission cost of 15-20 billion dollars annually, preventing unavoidable readmission rates is critical in improving patient’s quality of life, care and overall health and wellbeing (UpToDate, 2019). There has been a significant decrease in readmission rate with was in 2003 noted to be close to 20% of Medicare patients being readmitted within 30 days of discharge to 21.5 % in 2007 (UpToDate, 2019). With ongoing financial penalties allocated to acute and post-acute care settings by Medicare and other insurance companies coupled with patients quality of life and care, there is a great need to analyze, identify and implement new guidelines and change to care provision to reduce the readmission rate and improve patient outcomes in a timely manner. The clinical research evidence available shed a light on significant readmission rates, negative patient outcomes associated with these readmission rates and there is a continued need for further research and application of that research into clinically practice seeing significance difference in readmission rates and increased quality of care provided. As a DNP scholar my role remains that of taking on an active role in research, identifying gaps between clinical research and evidence available and clinical practice, and introducing change to current practice that will lead to better health outcomes, reduced readmission rates for these individuals and improved quality of care being provided. In post-acute care, how does frequent rounding and oversight by clinical provider and clinician on newly admitted patients in this setting compare to current guideline recommendations improve or lead to better hospital readmission rate over 8-week period. Current CMS guidelines on patient encounters with clinical provider in post-acute care setting recommends once every 30 days and when medically necessary. In acute care settings patientsInformation Systems Translation Science Project Guidelines. 4 are rounded by clinical providers daily and sometimes by multiple specialists daily which ensure full assessments and identification of problems before they become negative patient outcomes or worsening conditions. When these patients still sub-acute are discharged hastily into post-acute care settings, the providers see them once every 30 days per clinical guidelines and nursing staff have staggering patient to nurse ratio and patients begin to decompensate quickly and are not often identified until when its late and hence are hastily sent to the emergency departments and subsequently readmitted (CMS, 2019). In severe cases there are negative patient outcomes that can be fatal or affect patient’s overall recovery or return to prehospitalization functional levels. What difference would be experienced if these patients were rounded by clinicians more oftenseveral times weekly to quickly identify and intervene in case of decompensation and avoid rehospitalization and negative patient outcomes. Evidence Synthesis of Literature to Address the Selected Practice Problem. In conductive literature search to identify available evidence addressing rehospitalization rates effects of this populations of patients and ways to combat these trend, four research articles were selected. Hatipoğlu et al., 2018 addresses prediction of a 30-day All- Cause readmission