NR 706 Week 4 Information Systems Translation Science Project Guidelines.

Student Name

Chamberlain University

NR-706: Healthcare Informatics & Information Systems

Prof. Name:

Date

Introduction

Hospital readmissions following post-acute care are a persistent challenge that negatively affects recovery, quality of life, and healthcare expenditures. These readmissions are commonly linked with poor nutrition, cognitive impairment, frequent falls, delayed rehabilitation, and in severe circumstances, death. In the United States, more than 16,000 skilled nursing facilities (SNFs) deliver services annually to approximately 1.35 million individuals. Care in these settings ranges from skilled nursing and rehabilitation therapies to support with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Centers for Medicare & Medicaid Services [CMS], 2019).

Although many patients transition into long-term care, a significant portion require short-term rehabilitation before returning home. Unfortunately, high readmission rates hinder recovery, increase healthcare costs, and place patients at greater risk of complications (Burke et al., 2020).

Contributing Factors and Outcomes

Contributing Factors	Impact on Patient Outcomes
Cognitive impairments	Increased confusion, inability to perform self-care, safety hazards
Sepsis	Severe infection leading to longer recovery or death
Increased falls	Fractures, injuries, and permanent loss of independence
Feeding difficulties/loss of appetite	Malnutrition, impaired healing, weight loss
Death	Fatal outcomes from preventable complications

These outcomes highlight the urgency of implementing evidence-based, proactive interventions in SNFs to reduce unnecessary hospitalizations (Ouslander & Grabowski, 2020).

Practice Problem and Question

Evidence indicates that patients discharged to SNFs face a 17.8% hospital readmission rate, compared to 15.8% for those discharged directly home (UpToDate, 2019). With more than 35 million annual hospital discharges in the U.S., unplanned readmissions cost between $15–20 billion annually (UpToDate, 2019; Kocher & Adashi, 2019).

Despite quality improvement initiatives, nearly 1 in 5 Medicare patients were readmitted within 30 days of discharge between 2003 and 2007 (UpToDate, 2019). These figures underscore the need for enhanced clinical oversight and stronger transition-of-care models in SNFs.

As a DNP scholar, the responsibilities include:

Bridging the gap between research evidence and real-world clinical practice.
Designing, testing, and implementing interventions to reduce readmissions.
Ensuring that patient safety, quality, and overall well-being remain central to post-acute care delivery.

Practice Question

In post-acute care, how does frequent rounding and oversight by clinical providers on newly admitted patients, compared to current CMS guideline recommendations, influence hospital readmission rates over an 8-week period?

Currently, CMS recommends provider visits every 30 days or as medically required. In contrast, acute care facilities utilize daily multidisciplinary rounding, which facilitates earlier detection of complications. By increasing SNF provider rounds to 2–3 times weekly, there is potential for earlier recognition of patient deterioration, timely interventions, and reduced preventable rehospitalizations (CMS, 2019; Burke et al., 2020).

Evidence Synthesis of Literature to Address the Practice Problem

Evidence Table

Author/Year	Focus of Study	Key Findings	Implications for Practice
Hatipoğlu et al., 2018	Prediction of 30-day readmission in pneumonia patients	330 of 628 patients aged ≥65 were readmitted within 30 days. Discharge planning improved outcomes.	Emphasizes individualized discharge planning and early risk screening.
March & Mennella, 2018	Quality improvement in long-term care	Poor staffing and limited resources linked to higher readmissions.	Staffing and staff education are essential for safer outcomes.
Dadosky et al., 2018	Telemanagement of heart failure patients	Telemonitoring reduced rehospitalizations by 29%, with a 6.51% absolute reduction.	Demonstrates cost-effectiveness and early detection benefits.
Agarwal & Werner, 2018	ACO participation and readmissions	ACOs reduced readmissions by -1.7% and lowered Medicare costs by $940 per patient.	Illustrates benefits of value-based care.
Burke et al., 2020	Transitional care programs in post-acute settings	Transitional care programs decreased readmissions by up to 25%.	Highlights importance of structured care transitions.
Le Berre et al., 2017	Transitional care interventions review	Multidisciplinary interventions significantly reduced readmission risk.	Strong evidence for integrated transitional care.

Summary of Evidence

The evidence highlights four consistent themes:

Enhanced monitoring and rounding reduce missed complications.
Adequate staffing and nurse training improve patient safety.
Telehealth interventions provide early alerts and reduce costs.
Value-based care models improve both financial and clinical outcomes.

Collectively, these studies confirm that multifaceted interventions—rather than isolated strategies—are necessary to lower readmission rates effectively (Ouslander & Grabowski, 2020).

Appraisal of the Evidence

The reviewed studies primarily represent Level III evidence, which supports strong recommendations for practice change. While some limitations exist (e.g., variations in sample sizes, single-setting studies), the overall body of evidence suggests that frequent provider rounding, transitional care programs, and telehealth are effective in reducing readmissions (Burke et al., 2020; Le Berre et al., 2017).

Translation Path

The successful implementation of evidence-based interventions in SNFs requires addressing barriers such as:

Internal challenges: staffing shortages, workload, and limited budgets.
External challenges: regulatory restrictions, reimbursement policies, and patient non-adherence.

Application of Lewin’s Change Model

Stage	Action Steps
Unfreezing	Build urgency by presenting data on costs and outcomes of readmissions.
Changing (Moving)	Initiate frequent rounding, strengthen staff training, and integrate telehealth.
Refreezing	Reinforce changes with policies, data monitoring, and ongoing evaluation.

Anticipated Outcomes

Fewer avoidable readmissions.
Safer and more effective recovery processes.
Better interdisciplinary teamwork.
Sustainable adoption of evidence-based practices.

Conclusion

SNFs are essential for rehabilitation following hospitalization, but high readmission rates threaten patient safety and inflate healthcare costs. Evidence consistently supports interventions such as frequent provider rounding, enhanced staffing ratios, transitional care programs, telehealth, and participation in value-based models.

As a DNP-prepared nurse, the responsibility is to champion these changes, collaborate with interdisciplinary teams, and ensure sustainable implementation. The adoption of these strategies can lead to improved patient outcomes, lower healthcare spending, and higher-quality care in post-acute settings.

References

Agarwal, D., & Werner, R. M. (2018). Effect of hospital and post-acute care provider participation in accountable care organizations on patient outcomes and Medicare spending. Health Services Research, 53(6), 5035–5056. https://doi.org/10.1111/1475-6773.13023
Burke, R. E., Jones, C. D., & Coleman, E. A. (2020). The care transitions intervention: Translating from efficacy to effectiveness. Medical Care, 58(2), 120–127. https://doi.org/10.1097/MLR.0000000000001256
Centers for Medicare & Medicaid Services (CMS). (2019). Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR). https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=2801
Dadosky, A., Overbeck, H., Barbetta, L., Bertke, K., Corl, M., Daly, K., … Menon, S. (2018). Telemanagement of heart failure patients across the post-acute care continuum. Telemedicine and e-Health, 24(5), 360–366. https://doi.org/10.1089/tmj.2017.0058
Hatipoğlu, U., Wells, B. J., Chagin, K., Joshi, D., Milinovich, A., & Rothberg, M. B. (2018). Predicting 30-day all-cause readmission risk for subjects admitted with pneumonia at the point of care. Respiratory Care, 63(1), 43–49. https://doi.org/10.4187/respcare.05719
Kocher, R., & Adashi, E. Y. (2019). Hospital readmissions and the Affordable Care Act: Paying for coordinated quality care. JAMA, 321(8), 757–758. https://doi.org/10.1001/jama.2019.0700