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NHS FPX 6008 Assessment 2 Needs Analysis for Change

Student Name

Capella University

NHS-FPX 6008 Economics and Decision Making in Health Care

Prof. Name:


Needs Analysis for Change

This assessment aims to systematically analyze Tampa General Hospital (TGH) to identify the need to address particular healthcare economic issues. The issue identified at TGH is rehospitalization, resulting in several implications, including high costs and negative impacts on providers and patients. The paper will also explain evidence-based sources that advocate addressing similar needs to enhance patient safety, improve hospital efficiency, and manage overall workflows. Lastly, the predicted outcomes that will stem from sufficing the need to diminish rehospitalization rates will be analyzed.

 Summary of the Economic Issues of Rehospitalization

Rehospitalization is the term used to describe a patient’s readmission to the hospital for the same or a related condition soon after discharge, usually within 30 days. Rehospitalization raises the cost of healthcare dramatically because every readmission results in new costs for hospital stays, doctor visits, prescription drugs, and diagnostic testing. These expenses may burden patients and Florida’s healthcare systems, mainly if there are frequent or avoidable readmissions (Santiago et al., 2020).

Between 2010 and 2013, over 15% of stroke patients in Florida were readmitted to the hospital within 30 days. Additionally, the study reports that 3% of stroke patients experienced a recurrent stroke, and 12% of stroke patients were readmitted within 30 days as a result of vascular anomalies (Gardener et al., 2023).

Rehospitalization has harmed my work, the work of my colleagues, the organization—that is, Tampa General Hospital—and the whole community. Rehospitalization directly impacted the standard of care I gave my patients. It was discouraging for patients and healthcare professionals when patients were readmitted soon after being discharged because it meant that their medical needs had not been sufficiently met or attended to during their first hospital stay. The organization’s budgets and resources were strained due to the rising costs of hospital readmission rates.

NHS FPX 6008 Assessment 2 Needs Analysis for Change

High readmission rates made healthcare workers’ workloads and stress levels higher, which in turn caused burnout and a decline in job satisfaction. During readmission, the hospital also experienced a staffing shortfall, which eventually affected the standard of care provided by the institution. Overall, the community has been facing poor quality of care, further increasing hospital readmission rates.

The rationale for pursuing this issue is that it can escalate healthcare expenses, strain available resources, and degrade care quality (Santiago et al., 2020). Drawing from my experience as a nurse at TGH, I’ve observed the difficulties patients encounter post-discharge, contributing to their readmission despite educational efforts. The identified gap contributing to the onset of this healthcare economic issue is inadequate care coordination and poor care transition support for patients (Al Sattouf et al., 2022). This issue is particularly evident in vulnerable populations with limited follow-up care access.

Socioeconomic or Diversity Disparities

The impact of the income level of the low-socioeconomic population on readmission rates is a prominent socioeconomic disparity seen in the context of rehospitalization. Studies have repeatedly shown that patients with backgrounds of lower socioeconomic status pose a greater risk of rehospitalization than people with higher socioeconomic positions. One study showed that about 19.6% of readmissions were noted based on 30-day readmissions among patients with lower income levels (Feng et al., 2020). This evidence highlights how socioeconomic factors, such as income level, can influence the likelihood of rehospitalization.

Lower-income individuals may face barriers to accessing healthcare services, such as limited access to transportation or inability to afford medications or effective follow-up or rehabilitation care, contributing to higher readmission rates. Another study by Wong et al. (2022) observed that patients who acquired hip fracture surgery and belonged to low socioeconomic status showed higher readmissions considering 90-day readmission.  Addressing these socioeconomic disparities is crucial for reducing rehospitalization rates and improving health outcomes for all populations.

Evidence-Based Sources Advocating for Similar Change

Various evidence-based sources have shed light on this grave issue of rehospitalization or hospital readmissions. 

  1. One study by Hilton et al. (2022) emphasizes the need to address rehospitalization, mainly focusing on relating social determinants of health and their influence on post-sepsis readmission rates. The review concluded that the risk of readmission rates was increasing with lower-income patients who acquired sepsis discharge. Moreover, the study evaluated other SDOHs and their association with 30-day readmission, concluding with the pressing need to consider these disparities and their solutions to prevent readmission rates. 
  2. Another study conducted a systemic review on hospital readmission after heart failure. The review concluded that heart failure patients were rehospitalized to the hospital at a rate of 0.19 based on 30-day readmission. The study also highlighted the risk factors that lead to rehospitalization, highlighting the need to address this issue by considering factors causing higher hospital readmissions (Lan et al., 2021).
  3. Another study reported that patients with Chronic Obstructive Pulmonary Disease experience high rehospitalization rates at 30 days (2.6-82.2 %) due to acute exacerbations and potential risk factors. The authors also delved into implementing strategies such as national guidelines to prevent exacerbations and promote regular monitoring of symptoms to reduce rehospitalizations ultimately (Ruan et al., 2023).
  4. Another evidence-based source reported that patients with a history of heart failure were prone to higher hospital readmissions. The study discovered that readmission rates for men were more significant if the follow-up period was beyond a year. Women were more likely to be readmitted to hospitals when their readmission periods were less than a year. (Kim et al., 2020).

NHS FPX 6008 Assessment 2 Needs Analysis for Change

The evidence-based resources suggest implementing multifaceted and tailored plans such as enhancing care coordination, educating patients on follow-up care, promoting remote monitoring of disease symptoms, and addressing social determinants of health, particularly income status, that lead to higher rehospitalization rates (Diamond & DeVore, 2022). Additionally, adequate discharge planning, transitional care programs, and post-discharge follow-up are essential to intervention strategies to mitigate this healthcare economic issue (Pugh et al., 2021). These approaches can help mitigate the incidence of rehospitalization in TGH, ultimately lessening the financial burden on patients, providers, and organizations.

Predicted Outcomes and Opportunities

Implementing the proposed solutions and interventions to reduce rehospitalization rates offers several predicted outcomes and opportunities. By reducing rehospitalizations, healthcare organizations can optimize their revenue stream. Avoiding unnecessary readmissions prevents potential loss of reimbursement associated with penalties imposed by payers for excessive readmission rates. Furthermore, healthcare organizations can attract more patients by providing high-quality care (Al Sattouf et al., 2022). Moreover, preventing complications that may lead to readmissions enhances the revenue generation potential of the organization.

Additionally, the resources are utilized more effectively by streamlining care transitions, optimizing discharge planning processes, and promoting interdisciplinary collaboration (Al Sattouf et al., 2022). This efficiency translates into cost savings, reduced lengths of stay, and improved patient flow throughout the healthcare system. Preventing rehospitalizations contributes to higher levels of patient satisfaction and loyalty. Patients appreciate comprehensive care that addresses their needs and minimizes the likelihood of returning to the hospital. Positive experiences result in increased patient retention and referrals, benefiting the healthcare organization economically in the long term (Blum et al., 2020).

Above all, the proposed change and implementation plans of streamlining the care transition process by enhancing care coordination will offer a wide range of economic benefits for patients and TGH in terms of optimizing revenue streams, reducing additional hospital costs, enhancing operational efficiency, and improving patient satisfaction. Ultimately, TGH will achieve sustainable growth and success in providing high-quality care (Blum et al., 2020).


At TGH, rehospitalization is a prevailing healthcare economic issue due to a broader gap in care coordination and a better care transition process during patient discharge. Low income is a prominent identified socioeconomic disparity due to escalating readmission rates. Numerous evidence-based sources advocate addressing the issue of rehospitalization by preventing risk factors and better collaboration during the transition of care. The predicted outcomes and opportunities for addressing this concern will be optimized revenue streams, reduced additional hospital costs, enhanced operational efficiency, and improved patient satisfaction.


Al Sattouf, A., Farahat, R., & Khatri, A. A. (2022). Effectiveness of transitional care interventions for heart failure patients: A systematic review with meta-analysis. Cureus14(9). https://doi.org/10.7759/cureus.29726

Blum, M. R., Øien, H., Carmichael, H. L., Heidenreich, P., Owens, D. K., & Goldhaber-Fiebert, J. D. (2020). Cost-Effectiveness of transitional care services after hospitalization with heart failure. Annals of Internal Medicine172(4), 248. https://doi.org/10.7326/m19-1980 

Diamond, J., & DeVore, A. D. (2022). New strategies to prevent rehospitalizations for heart failure. Current Treatment Options in Cardiovascular Medicine24. https://doi.org/10.1007/s11936-022-00969-y 

Feng, T. R., Hoyler, M. M., Ma, X., Rong, L. Q., & White, R. S. (2020). Insurance status and socioeconomic markers affect readmission rates after cardiac valve surgery. Journal of Cardiothoracic and Vascular Anesthesia34(3), 668–678. https://doi.org/10.1053/j.jvca.2019.08.002 

Gardener, H., Romano, J. G., Derias, T., Gutierrez, C., Asdaghi, N., Johnson, K., Gordon Perue, G., Marulanda, E., Brown, S. C., Foster, D., & Rundek, T. (2023). Early hospital readmission following stroke: The Florida stroke registry. Frontiers in Stroke2https://doi.org/10.3389/fstro.2023.1238442 

NHS FPX 6008 Assessment 2 Needs Analysis for Change

Hilton, R. S., Hauschildt, K., Shah, M., Kowalkowski, M., & Taylor, S. (2022). The assessment of social determinants of health in postsepsis mortality and readmission: A scoping review. Critical Care Explorations4(8), e0722. https://doi.org/10.1097/cce.0000000000000722 

Kim, A. H., Parpia, C., Freitas, C., Austin, P. C., Ross, H. J., Wijeysundera, H. C., Tu, K., Mak, S., Farkouh, M. E., Sun, L. Y., Schull, M. J., Mason, R., Lee, D. S., & Rochon, P. A. (2020). Readmission rates following heart failure: A scoping review of sex and gender-based considerations. BMC Cardiovascular Disorders20(1). https://doi.org/10.1186/s12872-020-01422-3 

Lan, T., Liao, Y.-H., Zhang, J., Yang, Z.-P., Xu, G.-S., Zhu, L., & Fan, D.-M. (2021). Mortality and readmission rates after heart failure: A systematic review and meta-analysis. Therapeutics and Clinical Risk Management17, 1307–1320. https://doi.org/10.2147/tcrm.s340587 

Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence-based processes to prevent readmissions: More is better, a ten-site observational study. BMC Health Services Research21(1). https://doi.org/10.1186/s12913-021-06193-x 

Ruan, H., Zhang, H., Wang, J., Zhao, H., Han, W., & Li, J. (2023). Readmission rate for acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis. Respiratory Medicine206, 107090. https://doi.org/10.1016/j.rmed.2022.107090  

Santiago, M., Magro, F., Correia, L., Portela, F., Ministro, P., Lago, P., Trindade, E., & Dias, C. C. (2020). Rehospitalization rates, costs, and risk factors for inflammatory bowel disease: A 16-year nationwide study. Therapeutic Advances in Gastroenterology13, 175628482092383-175628482092383. https://doi.org/10.1177/1756284820923836

Wong, K. C., Tan, E. S.-E., Liow, M. H. L., Tan, M. H., Howe, T. S., & Koh, S. B. (2022). Lower socioeconomic status is associated with increased co-morbidity burden and independently associated with time to surgery, length of hospitalisation, and readmission rates of hip fracture patients. Archives of Osteoporosis17(1). https://doi.org/10.1007/s11657-022-01182-x 



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