Clinical Practice Experience (CPE) task

For this CPE, we define a Patient Care Transition Coordinator as a nurse who helps patients move from the hospital to a rehabilitation facility and then to their homes. Your role involves assisting specific patients through different levels and types of care. To perform this role successfully, you need to identify the education, experience, and skills required. As a Patient Care Transition Coordinator, your goal is to prevent hospitalization and re-hospitalization of patients returning home after hospitalization and rehabilitation.

The task consists of three phases in the healthcare continuum for a patient. You will explore evidence-based practices for a selected patient with conditions or procedures identified by the CMS Hospital Re-admissions Reduction Program (HRRP). Patient scenarios for each condition or procedure follow the instructions.

Transitions of care without readmission

You will focus on three phases:

1. Transition from hospital to home or sub-acute care facility
– Discuss the HRRP readmission reduction plan.
Research the CMS HRRP https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

2. Briefly discuss elements and criteria for the CMS HRRP conditions/procedures payment reduction plan for readmissions within 30 days of discharge.
– Provide an introduction to your patient and discuss pre-discharge initiatives to promote optimal recovery and prevent readmission within 30 days.

3. Develop/propose a Care Transition Plan for the patient with pneumonia.
– Incorporate individual, social determinants, community, system-level, and condition-specific considerations with a focus on preventing readmission within 30 days of discharge.

Reduction of all-cause, non-disease-specific readmissions

4. Research and discuss evidence-based practices for effectively transitioning patients from facility to home, with a specific focus on preventing all-cause hospital readmissions.
– Incorporate social determinants of health considerations impacting all-cause readmissions and how to prevent them.

5. Discuss evidence-based practices focused on preventing all-cause hospital readmissions.
– Incorporate individual, community, system, and social determinants of health considerations that impact all-cause readmission and how to prevent them.

Primary, secondary, and tertiary strategies to prevent hospitalization

6. Research and discuss approaches to impact/reduce hospitalization using primary, secondary, and tertiary prevention initiatives specific to your patient’s condition.
– Create an extension of the HRRP that focuses on preventing hospitalization through primary, secondary, and tertiary prevention methods.

Patient Chosen: Pneumonia

Lakshmi, a 73-year-old Indian female, is being discharged after a 4.5-day inpatient stay for community-acquired pneumonia (CAP). She started feeling ill ten days ago and sought care when her symptoms worsened. Lakshmi’s medical history includes osteopenia, a fractured femur from a motor vehicle accident in 1984, and migraine headaches. She has Medicare Advantage insurance.

Lakshmi’s lifestyle involves regular exercise, no smoking or alcohol, and a traditional Indian diet. She and her husband attend the local Hindu temple, and she participates in a neighborhood book club. She travels nationally and internationally 2-3 times per year.

Her medications include Vitamin D, calcium carbonate, levofloxacin, and Excedrin Migraine. She has no known allergies.