PICOT Question: In patients suffering from chronic health conditions (Population), how does transitional care interventions (Intervention) as compared to educating, managing, and scheduling medication (Comparison) reduce and prevent readmission of patients suffering from chronic conditions (Outcome) after two to three months of discharge (Time)?
Patient readmissions are worrying, thus posing quality care being offered in the various health care facilities. In 2005, America reported 17.6% readmissions within 30 days of discharge, accounting for $15 billion in spending in 2005 (Klein, 2020). This, therefore, means that health care providers provide inappropriate health care interventions with a lack of close monitoring of the patients leading to readmissions after a few days.
Evidence-based Intervention
Care transition with a collaborative approach is among the chronic care evidence-based interventions applied to other health care conditions in the quest to reduce the admission rates. “A study conducted by Salinas revealed that embracing collaborative care helps reduce unnecessary hospital readmissions through coordination of care, improved access to primary care, behavioral healthcare, specialty care, and improved utilization of standard processes and technology” (2019). Once a patient has been discharged, home caregivers should monitor the patient and report any complication exhibited through their visits. The intervention, which entails a multidisciplinary workforce who coherently works together under different timelines, helps practitioners understand the patient’s condition before being discharged. This approach will help patients suffering from chronic care conditions by closely monitored during and after being discharged to determine their response to medications and propose any improvement to medical the patient’s attention. As such, through patient-centred care, readmissions can be reduced.
Nursing intervention
Based on the conditions patients are suffering, which leads to readmission, for instance, patients suffering from Kidney conditions should have a transplant, which will reduce health care visits and improve their health. Therefore, proper medical attention, like transplants and surgery centers at the patient’s needs, is necessary to reduce chronic pain. According to Grinyo, transplants and surgeries are clinically important because they save lives, reduce suffering, and improve life (2013). As compared to patients who are frequently readmitted, these nursing interventions provide a long term solution to patients suffering from chronic conditions. Enhancing these medical interventions will positively help patients reduce being readmitted in their first one or two years unless it is health check-ups.
Patient care and Health Care Agency
Chronic illness patients require close care for better patient outcomes. Patients suffering from chronic heart failure might die at any time when not closely monitored due to different patterns of the illnesses’ signs and symptoms. Also, Care transition with a collaborative approach will help maintain close contact with the patient, thus facilitating quality care. For the intervention to be effective, all agencies need to learn and embrace it.
Nursing Practice
Nurses and other health care practitioners should apply the collaborative approach when the patient is admitted. The approach requires a multidisciplinary team to attend to the patient and provide the necessary care. At the same time, before any intervention is put into practice, the force must weigh the benefits and adverse impacts. Through intervention, helps caregivers share knowledge, work more efficiently and effectively, and make viable decisions. It also allows patients first positively to respond to medications before being discharged. Moreover, through practice, patients will be monitored through home visits and frequent communication with physicians.
