Advanced Health Assessment for Patients and Populations – D028: CDM1 Task 1: Clinical Practice Experience

Advanced Health Assessment for Patients and Populations – D028: CDM1 Task 1: Clinical Practice Experience

Step 2: Transition of Care Performance Assessment Document

Across healthcare contexts, the transition of patient care from the hospital to home or another facility is one of the most frequent, yet difficult tasks to achieve. A safe transition of care is not an easy task to achieve because it involves placing the patient in the hands of different providers. According to research, about one in five patients experience an adverse event during care transition leading to re-hospitalization or even death (McCarthy et al., 2018). Care transition is even risky to the elderly and individuals with chronic conditions that require close and continuous monitoring. While transitioning patient care to other facilities, it is crucial to consider costs and other determinants that may hinder the safe delivery of patient care.

Focusing on the issue of healthcare costs, the Centers for Medicare and Medicaid Services (CMS) has demonstrated concern in reducing costs associated with care transitions. The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions (CMS, 2020). This program is available to support the national goal of improving healthcare for Americans by linking payment to the quality of hospital care. The diagnosis of focus in this discussion is on Acute Myocardial Infarction (AMI) that is among the many conditions covered under HRRP.

Acute myocardial infarction encompasses a diverse cohort of patients with varying precipitating factors for cardiac injury. Type 1 and type 2 myocardial infarctions are the most frequently observed to cause readmissions in healthcare. For instance, AMI contributed $528 million under the HRRP in 2017. Additionally, about 10% of all readmitted patients that contribute to the HRRP penalties are observed to have AMI (McCarthy et al., 2018). The excess readmission ratio (ERR) is used to assess hospital performance to ascertain an excess number of AMI readmissions due to preventable factors. For eligible hospitals, the payment adjustment factor is calculated to determine the percentage of reducing reimbursements based on the ERR scores.

Readmissions following discharge after AMI can be caused by various reasons. Firstly, non-cardiac causes of readmission include comorbidities like diabetes, renal failure, and chronic lung disease. One of the most frequently observed causes for readmission is the development of infection. About 8.8% of AMI patients are readmitted due to infections and this significantly impacts penalties for associated healthcare facilities (Kwok et al., 2020). Another observed factor for unplanned readmission is discharged against medical advice. Most of the patients will come back with worsening symptoms that even cause prolonged hospitalization.

The hospital readmission reduction program is important because it addresses issues of quality care delivery to patients. The program emphasizes the engagement of patients and providers upon discharge to help in the development of a plan that can reduce readmissions. Additionally, HRRP is a crucial step towards the achievement of value-based purchasing that rewards institutions according to the quality of care delivered. With varied readmission rates across the country, HRRP gives each institution an equal opportunity to provide standardized quality care to patients to save taxpayer dollars.

Clinical Summary

Donald is a 55-year-old male patient being discharged after a 5-day treatment following myocardial infarction. Upon admission, interventions included angioplasty and placement of two cardiac stents. Donald’s discharge plan includes seeing a cardiologist after two weeks, starting cardiac rehabilitation after one week, and having laboratory blood drawn in 5 to 7 days.

Preventing readmission for this patient will include the following strategies:

  • Ensuring Donald adheres to the follow-up plan with his cardiologist.
  • Follow-up calls to ascertain ambulation while at home.
  • Routine follow-up to ensure he takes all medications correctly.

STEP 3: Evidence-Based Practice Preventing All-Cause Hospital Readmission

Evidence-Based Strategies

Transitioning home after hospitalization is followed by a series of events that can affect the patient’s condition ranging from full recovery to rehospitalization. One of the causes of rehospitalization is disengagement from the primary care providers leading to non-compliance to the initial treatment plan (Kwok et al., 2020). Failure to adhere to follow-up plans and lack of communication with the healthcare providers increases the chances of readmissions. Secondly, complications arising from the condition, especially after surgery can cause readmission. Individuals with chronic conditions like myocardial infarction and CCF can be re-hospitalized due to complications. Additionally, the inadequate transition of care is a factor that leads to rehospitalization in many cases. Poor coordination of care, inadequate delivery of discharge information, and communication breakdown contribute to readmission.

Various evidence-based strategies are available to reduce hospital readmissions following discharge to home. The first strategy involves assigning nurses or primary care providers to patients to manage medication plans (Pugh et al., 2021). Each provider deals with a specific number of patients or patients with certain conditions to ensure timely follow-up and communication of care. Secondly, partnering with local physicians and physician groups is a strategy that demonstrates improved patient care upon discharge (Pugh et al., 2021). Hospitals should establish communication with the physicians to allow timely referral and consultations to prevent deterioration of the patient’s condition. Another crucial strategy is the use of the teach-back method where the patient is required to repeat knowledge on given education about their condition and subsequent care at home (Pugh et al., 2021). Lastly, the use of modern technology provides an opportunity to reduce readmissions. Various education videos and applications are available to guide patients through their routine care without the direct involvement of their primary care providers.

Apart from the patient’s medical condition, several other factors can affect readmissions. For instance, poor social planning, especially among the elderly can lead to worsening of the patient. The discharge plan should include the individual going to take care of the patient at home and failure to acknowledge this factor affects subsequent treatment at home. Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks (McCarthy et al., 2018). I relation to hospital readmission, the level of poverty can influence the health-seeking behavior of patients including the purchase of medication leading to poor health. If an individual is unable to buy drugs, they are likely to come back with worsened symptoms leading to readmission.

Effect on the Patient

Donald is a patient discharged home following surgery after suffering from AMI. One of the factors that can cause readmission for the patient is a lack of compliance with the follow-up plan. As explained in the patient’s history, Donald had a primary care provider who he last saw 7 months ago. Currently, he is supposed to see a cardiologist after a week and failure to adhere to these instructions can lead to readmission. Another possible factor to consider is Donald’s lifestyle choice that has contributed to obesity and hyperlipidemia. Although the patient is on Artovastatin, his diet mostly involves fast foods. Lack of dietary modification at home can contribute to the worsening of his condition.

Donald’s case scenario indicates that his health is affected by various social determinants. To improve his health and prevent readmission, the following interventions can be used.

  • Individual level: Dietary education for low-fat health diet to prevent obesity. The patient’s health literacy level requires improvement.
  • Social/community level: Ensure the patient’s families are active participants in Donald’s treatment and follow-up plan. Wife to accompany the patient during follow-up to improve compliance levels.
  • Systems level: Donald’s treatment plan involves long-term care including regular visits and the use of OTC medications. Contacting his insurance company (Blue Cross Blue Shield) will serve to promote pharmaceutical assistance. 

STEP 4: Hospital Prevention Plan with Individual, Social/Community, and Systems-Level Interventions

Primary Prevention

Primary prevention involves activities performed to prevent disease or injury before it occurs (Karunathilake & Genegoda, 2018). For individuals with cardiovascular diseases, physical activity and exercise are among the primary prevention strategies that can be helpful. The following primary prevention strategies can be used to manage AMI observed in the patient.

  • Individual level: Engage in routine physical activity and exercise. Exercise will help in managing weight, preventing obesity, and definitely minimize chances of getting AMI.
  • Social/Community level: Passing of laws to minimize the selling of fast foods that contribute to weight gain and obesity.
  • Systems level: Provision of information to the public about the risks to cardiovascular disease and available services in healthcare facilities.

Secondary Prevention

Secondary prevention deals with early detection when improves the chances for positive health outcomes (Karunathilake & Genegoda, 2018). The following interventions can be used to promote health of Donald.

  • Individual level: Ensure adherence to medications and exercise for overall improvement of health. The patient should also regularly visit his cardiologist.
  • Social/Community: Population-based screening for overweight and obesity for early detection of disease. Establishment of support services in hospitals for routine screening e.g. dyslipidemia screening.
  • Systems level: Pharmaceutical assistance for medications through insurance approval. The strategy will increase the proportion of individuals able to purchase medications for AMI treatment.

Tertiary Prevention

Focuses on individuals that are already affected by a disease to improve quality of life by reducing disability, limiting or delaying complications, and restoring function (Karunathilake & Genegoda, 2018). Tertiary prevention for Donald’s condition may include:

  • Individual level: Routine visits to the cardiologist for screening of complications following angioplasty and placement of two cardiac stents.
  • Social/Community: Creating support groups for people living with heart disease in the community. Donald can benefit from support groups, especially individuals that have survived AMI.
  • System’s level: Ensuring the patient’s insurance can cater for subsequent treatment including costly surgeries. Improving telecommunication services and emergency services following AMI calls.


Centers for Medicare and Medicaid Services. (2020). Acute inpatient PPS: Hospital readmissions reduction program (HRRP).

Karunathilake, S. P., & Ganegoda, G. U. (2018). Secondary prevention of cardiovascular diseases and application of technology for early diagnosis. BioMed Research International2018, 5767864.

Kwok, C. S., Capers, Q., 4th, Savage, M., Gulati, M., Potts, J., Mohamed, M. O., Nagaraja, V., Patwala, A., Heatlie, G., Kontopantelis, E., Fischman, D. L., & Mamas, M. A. (2020). Unplanned hospital readmissions after acute myocardial infarction: A nationwide analysis of rates, trends, predictors and causes in the United States between 2010 and 2014. Coronary Artery Disease31(4), 354–364.

McCarthy, C. P., Vaduganathan, M., Singh, A., Song, Z., Blankstein, R., Gaggin, H. K., Wasfy, J. H., & Januzzi, J. L., Jr (2018). Type 2 myocardial infarction and the hospital readmission reduction program. Journal of the American College of Cardiology72(10), 1166–1170.

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), 189.