D117 Care Plan for Transition- Phase 1

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Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

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Date

Overview of the CMS Hospital Readmissions Reduction Program

In 2012, federal legislation mandated the Centers for Medicare and Medicaid Services (CMS) to implement a value-based purchasing initiative designed to improve patient outcomes through enhanced communication, discharge planning, and care coordination. This initiative, formally known as the Hospital Readmissions Reduction Program (HRRP), links hospital reimbursement to performance metrics associated with preventable hospital readmissions (Centers for Medicare & Medicaid Services [CMS], 2023). The primary objective of HRRP is to reduce avoidable 30-day readmissions by incentivizing hospitals to implement evidence-based transitional care strategies that actively engage patients and caregivers during the discharge process.

Under HRRP, CMS evaluates hospitals based on six clinical categories: acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA). Hospitals with readmission rates exceeding expected benchmarks may incur payment penalties of up to 3%. Although this percentage may appear modest, it represents a substantial financial and reputational incentive for healthcare organizations to analyze readmission trends and optimize discharge planning practices.

Importance of Transitional Care Planning in Reducing Readmissions

Unplanned hospital readmissions are frequently multifactorial and often linked to system-level failures rather than unavoidable disease progression. Common contributors include ineffective communication among providers, medication discrepancies, inadequate follow-up planning, and insufficient patient education. Feigenbaum et al. (2012) identified missed opportunities in transitional care planning, medication management, logistics of follow-up care, and coordination among multidisciplinary teams as significant contributors to 30-day readmissions. These findings emphasize that structured transitional care planning can meaningfully reduce preventable readmissions when appropriately implemented.

Elective primary total hip arthroplasty is a targeted condition under HRRP, requiring healthcare teams to apply standardized, best-practice transitional care plans for all patients, regardless of whether they are discharged home or to a skilled nursing facility. Given the elective nature of THA, many post-discharge complications are predictable and therefore preventable with proactive planning.

Clinical Risks and Common Causes of Readmission Following Total Hip Arthroplasty

Patients undergoing THA are vulnerable to several postoperative complications that can result in unplanned hospital readmission. According to Kurtz et al. (2018), the most frequently reported causes include surgical site infections, atrial fibrillation, pulmonary embolism, septicemia, and pneumonia. These complications underscore the necessity of targeted education, vigilant monitoring, and timely follow-up during the transition from hospital to home.

Table 1 outlines common post-THA complications and associated preventive strategies.

Table 1
Common Post-THA Complications and Preventive Interventions

Potential Complication	Risk Factors	Preventive Strategies
Surgical site infection	Obesity, diabetes, poor wound care	Antibiotic adherence, wound hygiene education
Deep vein thrombosis / pulmonary embolism	Immobility, obesity	Anticoagulation, early ambulation
Pneumonia	Reduced mobility, shallow breathing	Incentive spirometry, ambulation
Joint dislocation or injury	Improper movement, unsafe home	Joint precautions, home safety modifications
Medication-related adverse events	Polypharmacy, allergies	Medication reconciliation, patient education

Patient Case Scenario: Susan

The patient case used to contextualize this care transition plan involves a 68-year-old female, referred to as Susan, with advanced osteoarthritis requiring elective total hip arthroplasty. Susan presents with multiple comorbidities, including obesity (BMI 36.9 kg/m²) and a history of depression. These factors not only contributed to her need for surgical intervention but also increase her risk for postoperative complications and hospital readmission.

Role of the APRN in Preventing 30-Day Readmission

The Advanced Registered Nurse Practitioner (APRN) plays a critical role in coordinating Susan’s discharge plan and mitigating readmission risks. A primary focus involves infection prevention. Susan should complete the prescribed course of oral antibiotics following surgery. Due to her documented penicillin allergy, clindamycin is an appropriate alternative; however, its association with Clostridioides difficile infection necessitates patient education regarding early symptom recognition, including persistent or bloody diarrhea.

Susan must also receive clear instructions on maintaining surgical site cleanliness and promptly reporting signs of infection such as redness, warmth, swelling, pain, or purulent drainage. Reinforcing that postoperative concerns should be directed to the orthopedic surgeon is essential, as continuity of care remains under surgical management until formal discharge from specialty care.

Medication Management and Anticoagulation Strategies

Effective medication reconciliation is fundamental to ensuring continuity of care and preventing adverse drug events. Susan should be discharged with a comprehensive medication list provided to both her and her primary care provider. This list should clearly outline medication names, dosages, schedules, and purposes.

To reduce the risk of thromboembolic events, Susan should adhere to a prophylactic regimen that includes daily low-dose aspirin, continuation of injectable enoxaparin until completion, and regular ambulation. Pain management should incorporate a multimodal approach, including NSAIDs, opioids as prescribed, and scheduled acetaminophen, to facilitate mobility while minimizing complications associated with immobility.

Nutritional and Weight Management Considerations

Susan’s obesity presents additional challenges to postoperative recovery and long-term joint health. Initially, she should be encouraged to consume a soft, bland diet and advance as tolerated. Emphasis should be placed on a balanced, protein-rich diet to support wound healing and tissue repair. Following recovery, her primary care provider can address sustainable weight management strategies to reduce stress on the prosthetic joint and prevent further musculoskeletal degeneration.

Mobility, Physical Therapy, and Home Safety

Preventing injury to the newly replaced joint requires strict adherence to hip precautions taught during inpatient physical therapy. Susan and her family should receive education on safe movement techniques and environmental modifications to reduce fall risk. Recommended interventions include removing household clutter, installing raised toilet seats, using shower chairs, and employing pillow wedges and bed risers.

Durable medical equipment, including a walker and continuous passive motion (CPM) machine if prescribed, should be delivered to Susan’s home prior to discharge. Outpatient physical therapy appointments must be confirmed before discharge, with transportation arrangements addressed to ensure compliance.

Prevention of Pulmonary Complications

Pulmonary complications represent another preventable cause of readmission following THA. Susan should be instructed to continue incentive spirometry, perform regular coughing and deep-breathing exercises, maintain adequate hydration, and ambulate frequently. These measures reduce the risk of atelectasis and subsequent pneumonia. Written instructions should be provided in clear, accessible language to reinforce adherence.

Multidisciplinary Discharge Planning and Social Support

Prior to discharge, Susan should be evaluated by a multidisciplinary team including physical therapy, occupational therapy, and social work to determine her safety for home discharge. Social determinants of health, such as access to transportation, prescription refills, grocery shopping, and family support, must be addressed. Without adequate logistical support, Susan’s risk of readmission increases significantly.

Professional Review and Quality Improvement

This care transition plan was reviewed by MaryEllen Kopp, APRN, a postsurgical cardiac advanced practice provider. Her feedback emphasized the importance of multidisciplinary clearance for home discharge, heightened vigilance for Clostridioides difficile infection, and explicit education regarding wound infection symptoms. These recommendations were incorporated to strengthen the quality and clinical relevance of the care plan and will inform subsequent phases of this academic series.

References

Centers for Medicare & Medicaid Services. (2023). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Feigenbaum, P., Neuwirth, E., Trowbridge, L., Teplitsky, S., Barnes, C., Fireman, E., Dorman, J., & Bellows, J. (2012). Factors contributing to all-cause 30-day readmissions: A structured case series across 18 hospitals. Medical Care, 50(7), 599–605. https://journals.lww.com/lwwmedicalcare/Abstract/2012/07000/Factors_Contributing_to_All_cause_30_day.7.aspx