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In this CPE, you will experience the role of a graduate degree prepared nurse who is a Patient Care Transition Coordinator. For the purpose of this CPE, a Patient Care Transition Coordinator is defined as a nurse who focuses on assisting patients moving from the hospital to a rehabilitation facility, and then to their homes. During this experience, you will help specific patients move through different levels and types of care. You will identify the education, experience, and skills required for you to perform this role successfully. Additionally, as a Patient Care Transition Coordinator, you should aim to prevent hospitalization and rehospitalization of patients who returned to their homes after hospitalization and rehabilitation.
In this CPE, you will experience the role of advanced professional nurse in the transitions of care from hospital to home or sub-acute or chronic facility.
The task is comprised of three phases of the transitions of healthcare continuum for a patient. You will examine and discuss evidence-based practices for a selected patient with one of the conditions or procedures identified by the CMS Hospital Readmissions Reduction Program (HRRP). Patient scenarios for each of the conditions or procedures follow the instructions.
The three phases on which you will focus are:
· Transition from hospital to home or sub-acute care facility
· Discuss the HRRP readmission reduction plan.
· Provide introduction to your patient and discuss pre-discharge initiative/interventions to promote optimal recovery and prevent readmission within 30 days or less.
· Reduction of all-cause, non-disease-specific readmissions
· Research and discuss evidence-based practices for effectively transitioning patient from facility to home with specific focus on preventing all-cause hospital readmissions.
· Incorporate social determinants of health considerations that impact all-cause readmissions and how to prevent them with focused interventions or initiatives for your patient targeting the individual, community, and system levels.
· Primary, secondary, and tertiary strategies to prevent hospitalization
· Research and discuss approaches to impact/reduce hospitalization utilizing primary, secondary, and tertiary prevention initiatives focusing on the individual, community, and system level specific to your patient’s condition or procedure.
Student Instructions:
· Type in your name and date at the top of this form
· Type in the name of your assigned course instructor
· Complete and date the required activities
· Submit the completed CPE record for evaluation as a word document or .pdf in the assessment tab for the task.
·
STEP 2
· Research the CMS HRRP
· Briefly discuss the elements and criteria used for the CMS HRRP conditions/procedures payment reduction plan for readmissions within 30 days of discharge.
· Develop/propose a Care Transition Plan for the patient with the condition or procedure that you chose for your CPE.
· Incorporate individual, social determinants, community, system-level, and condition/procedure specific considerations with emphasis on interventions and initiatives to prevent readmission within 30 days of discharge.
PHASE 2: Identifying EBP for the Prevention of Hospital Readmission
STEP 3
· Research the evidence-based practices for effectively transitioning patients from the hospital (& rehabilitation unit) to home with the specific focus on preventing all-cause hospital readmission. Utilize your textbooks, online resources, and other sources as needed.
· 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.
PHASE 3: Development of a Hospital Prevention Plan
STEP 4
· Based on research, create an extension of the HRRP that focuses on successfully preventing hospitalization through primary, secondary, and tertiary prevention methods.
· Initiatives should incorporate individual, social, community, system-level, and condition/procedure specific considerations.
STEP 5
· Record and post one 3–5 minute GoReact https://lrps.wgu.edu/provision/303936046
video reflection discussing what you accomplished and learned from each of the components of your transitions of care paper in CPE phase 3.
· Summarize your reflection and paste under a screenshot of your video
· Watch two peers’ videos and provide them encouraging and constructive feedback.
· Take a screenshot of your peers’ videos with your comments and paste them into your document prior to the references.
FINAL STEP
· Copy and paste each of the phase elements into the matching phase tab in your e-portfolio
· Provide a shared link to your e-portfolio
Advanced Health Assessment of Patients and Populations CPE Case Scenarios
Directions:
As the Patient Care Transition Coordinator, you are tasked with effectively transitioning patients home and helping them to avoid readmission to the hospital. Choose one of the following HRRP conditions or procedures patient scenarios and create a comprehensive transition and prevention plan based on the information provided. Review the CPE Record document carefully for directions on completing the comprehensive transition and prevention plan components for Phase 1, 2, and 3 of the Clinical Practice Experience for this course.
Acute MI
Donald is a 55-year-old Hispanic male who is being discharged from the hospital after a 5-day inpatient stay for treatment of acute myocardial infarction (MI). Five days ago, Donald felt chest tightness, nausea, and shortness of breath while gardening at home. After telling his wife about his symptoms, an ambulance was called and he was transported to the local hospital emergency department where the patient history, physical examination, and diagnostic tests were all strongly suggestive of acute MI. Within 50 minutes of his first symptoms, Donald was in the cardiac catheterization lab where an angioplasty was performed, and two cardiac stents were placed without complication.
During the remainder of his hospital stay, Donald started taking three new medications, received education about lifestyle modification, and began light walking on the unit. He will be discharged home today, with plans to see his cardiologist in two weeks, start cardiac rehabilitation in one week, and have laboratory blood draws in 5-7 days. Donald was followed by a hospitalist while receiving inpatient care and does not have an appointment to see his primary care provider, who he last saw 7 months ago.
Donald’s other history is as follows: Ht: 5’10” WT: 245 BP: 116/78 Temp: 98.2 F O2 sats: 98% on RA Pain: 1/10 at groin access point.
Insurance: Blue Cross Blue Shield
PMH: Hypertension for 15 years-treated with Lisinopril. Obesity (BMI 35 kg/m2)-untreated. Hyperlipidemia untreated. Tonsillectomy at 15 years of age. Right knee ACL repair at 36 years of age.
FH: Father deceased, MI at 62. Mother alive, 80, DM II, HTN, osteoporosis. Daughter, 20, alive and well, son, 17, alive and well.
SH: Bachelors and Masters degrees in mathematics. Community college math professor. Salary of $75,000 per year with state benefits. Married with two children at home. Wife works as an accountant. Home is in a well-maintained neighborhood with sidewalks, a nearby park, and a grocery store 0.5 miles away. Donald usually eats at restaurants, the college cafeteria, or fast food 6-8 times a week. Walks for exercise once a week for 15-20 minutes. No smoking history. Drinks 2-4 beers on weekends socially, 3-4 times a month. No illicit drug use. Two cups of coffee per day, and one regular coke daily. Donald and his family attend a local church weekly, and are active participants with local social groups. Extended family for both Donald and his wife live nearby, within 30 minutes of their home.
Meds: Atorvastatin 80 mg tab, 1 tab daily by mouth. Atenolol 25 mg tab, 1 tab every 12 hours by mouth. Lisinopril 10 mg tab, 1 tab daily by mouth. Clopidogrel 75 mg tab, 1 tab daily by mouth. Aspirin 81 mg tab, 1 tab daily by mouth.
Allergies: NKDA, No food or environmental allergies.
COPD
Marcia is a 63-year-old white female who is being discharged from the hospital after a 4-day inpatient stay for treatment of Chronic Obstructive Pulmonary Disease (COPD). During the two weeks prior to hospitalization, Marcia noticed increasing shortness of breath that progressed from dyspnea with moderate exertion to dyspnea at rest, copious amounts of non-bloody sputum production, and a nagging, hacking cough that kept her up at night. Marcia was dropped off at the emergency department by a friend four days ago because she was not able to secure an appointment with her primary care provider due to the provider’s schedule being full for the next 3 weeks. This is Marcia’s second hospitalization for COPD in the past year.
While hospitalized, Marcia’s COPD medications were changed (she was managed with albuterol only), she used nicotine gum instead of smoking, and performed inpatient pulmonary therapy yesterday. Marcia will be discharged home today, with instructions to contact the pulmonology office to schedule an appointment at her earliest convenience. Pulmonary rehabilitation has been ordered, but no one has contacted her to initiate the service. Marcia was treated by a hospitalist while receiving inpatient care and does not have an appointment to see her primary care provider at the local community health clinic. Often Marcia must wait 3-5 weeks to get into the clinic when she calls for an appointment.
Marcia’s other history is as follows: Ht: 5’3” WT: 165 BP: 125/88 Temp: 98.6 F O2 sats: 95% on RA Pain: 0/10.
Insurance: Medicaid.
PMH: COPD for 12 years. Overweight (BMI 29 kg/m2). Hypertension-Lisinopril 20mg. Total hysterectomy at 45 years of age. Osteopenia since 58 years of age.
FH: Father deceased, 76, Lung CA. Mother deceased, 84, CHF. Son, 40, asthma. Son, 37, alive and well. Daughter 34, alive and well.
SH: High School Diploma. Part-time cashier at a department store. Salary of $15,800 per year without benefits. Divorced, living alone, three children live within 45 minutes of her home. Marcia lives in a 55 and above low-income apartment complex that is poorly maintained. The neighborhood is located in a downtown urban area with broken sidewalks, no nearby parks, and the nearest grocery store is 3 miles away. Marcia eats canned and processed frozen foods at home. Does not exercise. Smokes ½ pack a day, with a 25-pack- year history. Drinks wine rarely, once or twice a year at holiday functions. Does not drink coffee. Drinks 2-3 cans of diet Pepsi daily. No illicit drug use. Marcia does not interact with any social groups outside of work and her family. Marcia does not own a car and takes public transportation to work and to run errands.
Meds: Lisinopril 20 mg tab, 1 tab daily by mouth. Vit-D 1000 U tab, 1 tab daily by mouth. Doxycycline 100 mg tab, 2 tabs by mouth daily x 7 days (2 days remaining). Prednisone 20 mg tab, 2 tabs daily by mouth for 10 days (5 days remaining). Tiotropium 18 mcg capsule, 1 capsule inhaled once daily. Albuterol 90 mcg/actuation, 2 puffs by mouth every 4-6 hours as needed for shortness of breath. Allergies: Penicillin-itchy rash, no food or environmental allergies.
HF
Reggie is a 72-year-old black male who is being discharged from the hospital after an eight-day inpatient stay for treatment of Heart Failure exacerbation (HF). This is Reggie’s fourth hospitalization for HF in the last three years. Prior to being hospitalized, Reggie noted that his legs became severely swollen, his abdomen was distended, and he started feeling short of breath. When his daughter brought him a meal, she noticed how swollen his legs were, and how ill he looked. She called his primary care provider, who suggested that Reggie be taken to the local ER. Soon after arriving at the ER he was admitted to the telemetry unit for treatment of an exacerbation of HF.
During his hospital stay, Reggie was treated with Lasix, potassium supplements, as well as his normally prescribed medications. The Lasix and potassium supplements were discontinued yesterday. He maintained a strict low sodium cardiac diet, with fluid restriction to 1500 cc per day. Additionally, Reggie and his daughter received education about lifestyle modification for HF and diabetes. Reggie will be discharged home today, with plans to see his cardiologist in one week, have laboratory blood draws in one week, and see his primary care provider as soon as possible. Reggie was treated by his usual cardiologist while in the hospital, and a hospitalist. Records of his hospitalization will be digitally sent to his primary care provider.
Reggie’s other history is as follows: Ht: 6’0” WT: 265 BP: 112/74 Temp: 98.8 F O2 sats: 96% on RA Pain: 0/10
Insurance: Medicare Advantage Plan (Coverage for A-D)
PMH: Hypertension for 40 years. Obesity (BMI 35.9 kg/m2). Hyperlipidemia. DM II. Appendectomy at 42. Bilateral osteoarthritis of the knees.
FH: Father deceased, lung cancer at 68. Mother deceased, MI at 80, DM II, HTN. Son, 47, DM II, hyperlipidemia. Daughter, 45, HTN. Son, 42, alive and well.
SH: Bachelors degree in civil engineering. Retired civil engineer. Widower of 3.5 years, with three grown children. Oldest son lives out of state. Daughter lives in the same city. Youngest son lives several hours away. Reggie lives in the same home he has occupied for 40 years in a well-maintained neighborhood with wide sidewalks, two nearby parks, and several local grocery stores with a wide variety of fruits and vegetables, both are about one mile from his home. Reggie eats frozen and canned foods often, especially since his wife passed away from breast cancer 3½ years ago. He does not exercise regularly. No smoking history. Does not drink alcohol. One cup of coffee per day with sugar and creamer. No soda but does drink orange juice with breakfast and vegetable juice with his dinner. Reggie and his wife attended a local church weekly, he has attended sporadically since her death. Reggie used to participate in a local hobby builder group, but has not attended meetings for over a year. Other than his daughter nearby, Reggie has no extended family nearby.
Meds: Metoprolol XL 25 mg, 1 tab daily by mouth. Lisinopril 10 mg tab, 1 tab daily by mouth. Aspirin 81 mg tab, 1 tab daily by mouth. Aldactone 25 mg tab, 1 tab daily by mouth in the morning. Metformin HCl 500 mg tab, 2 tabs each am with breakfast, 1 tab each pm with dinner. Simvastatin 40 mg tab, 1 tab daily by mouth. Tylenol 500 mg tab, 1-2 tabs as needed by mouth for knee pain (do not exceed 3 grams daily).
Allergies: NKDA, No food allergies, minor seasonal allergies.
Pneumonia
Lakshmi is a 73-year-old Indian female who is being discharged from the hospital after a 4.5-day inpatient stay for treatment of community acquired pneumonia (CAP). Lakshmi started feeling ill ten days ago, and thought that her cough, fever, and body aches were either a bad cold or maybe the flu. When her symptoms seemed to worsen and she started feeling short of breath, she went to a local urgent care for an examination. The provider in the urgent care collected her health information, conducted a physical examination (coarse breath sounds in the lower lobes), and performed a chest x-ray which showed right lower lobe pneumonia. Lakshmi’s blood pressure at the urgent care was 88/65, her BUN was 10, she was not confused, and her respiratory rate was 24. The provider explained the benefits of hospitalization versus in-home treatment, CURB-65 score, and recommendation for hospitalization. Lakshmi agreed with that plan, the provider called the local hospital to arrange for a direct admit, and Lakshmi’s husband drove her to the hospital.
While hospitalized, Lakshmi continued her normal medications and was also given intravenous antibiotics. Additionally, she was given 2L of oxygen by nasal cannula. Lakshmi will be discharged home today, with plans to follow up with her primary care provider in the next two weeks.
Lakshmi’s other history is as follows (at discharge): Ht: 5’1” WT: 123 lbs BP: 106/68 Temp: 98.2 F O2 sats: 98% on RA Pain: 0/10
Insurance: Medicare Advantage
PMH: Osteopenia, 2014. Fractured femur, motor vehicle accident, 1984. Migraine headaches.
FH: Father deceased, stroke at 68. Mother alive, 98, osteoporosis, hearing loss. Son, 47, alive and well.
SH: Lakshmi was born and raised in an affluent part of India and emigrated to the US to pursue her education. She has a bachelor’s degree in biology and a master’s degree in microbiology. She is a retired microbiologist. She is married with one child who lives several states away with his family. Husband is a retired financial analyst. They live in a downtown high-rise condominium next to a city park. There are several grocery stores within a 0.5 mile walk from their condo. Lakshmi and her husband often trade off cooking duties and eat traditional Indian cuisine at home. Lakshmi walks for exercise 5 days a week for 30-45 minutes. No smoking history. Does not drink alcohol. Drinks black tea two to three times a day, and no soda. Lakshmi and her husband attend the local Hindu temple for worship and meals, 1-2 times per week. She is also part of a neighborhood book club and travels nationally and internationally 2-3 times per year.
Meds: Vit-D 1000 U tab, 1 tab per day. Calcium carbonate 600 mg tab, 2 tabs daily. Levofloxacin 750 mg tab, 1 tab daily for 2 days. Excedrin Migraine 2 tabs by mouth every 24 hours as needed for migraine.
Allergies: NKDA, No food or environmental allergies.
CABG
Frank is a 76-year-old male who is being discharged from a skilled nursing facility (SNF) after coronary artery bypass graft surgery (CABG) 18 days ago. Frank spent 6 days in the hospital, and 12 days in the SNF. Frank previously had three heart attacks, two of which were treated with angioplasty and stents. The last heart attack occurred 20 days ago, and the decision was made to proceed to surgery.
While in the hospital and SNF, Frank continued his previous medications, started cardiac rehab, and began physical therapy once a day. He will be discharged home today, with plans to see his cardiologist in two weeks, start home health physical therapy in the next two days, and have an appointment with his primary care provider in the next two weeks.
Frank’s other history is as follows: Ht: 5’8” WT: 190 BP: 114/80 Temp: 98.4 F O2 sats: 97% on RA Pain: 2/10 incisional wound pain.
Insurance: Traditional Medicare
PMH: Hyperlipidemia. MI (55, 68, 76). DM II for 15 years. Degenerative joint disease-back.
FH: Father deceased, MI at 50. Mother deceased, CHF at 87. Daughter, 49, alive and well. Son, 46, HTN and hyperlipidemia. Son, 43, alive and well.
SH: High school diploma. Retired plumber. Receiving $6,500 in combined Social Security and retirement monthly. Married with three children who live nearby. Wife is a retired administrative assistant. They live in a home they have owned for 50 years. The neighborhood has high crime, the nearby park is often a campsite for multiple homeless individuals. There is a local grocery store less than one miles from their home. Frank and his wife usually eat home cooked meals that consist of red meat, potatoes, breads, one fruit and two vegetables per day. Frank walks for exercise, twice a week at the local indoor mall for 30 minutes. Frank quit smoking 18 years ago. Frank drinks 1-2 beers per week, one cup of coffee per day, and 1-2 diet sodas daily. Frank and his wife attend a local church once or twice a month, and frequently go to dinner and the movies with a close group of friends. Extended family for Frank live out of state. His wife’s extended family live nearby.
Meds: Atorvastatin 80 mg tab, 1 tab daily by mouth. Metoprolol ER 25 mg tab, 1 tab every 12 hours by mouth. Aspirin 81 mg tab, 1 tab daily by mouth. Naproxen 220 mg, 1 tab by mouth twice daily as needed. Epipen 0.3 mg IM injection as needed for bee sting.
Allergies: NKDA, No food allergies. Bee venom-anaphylaxis.
Total Hip and/or total knee
Susan is a 68-year-old white female who is being discharged from the hospital after a 4-day inpatient stay post left total hip arthroplasty (THA). Susan had dealt with severe osteoarthritis of both hips, with the left hip having the most severe degenerative changes. Four days ago she had the elective THA and has had an uneventful recovery.
While in the hospital, Susan continued to take her normally prescribed medications with the addition of NSAIDS, acetaminophen, Gabapentin (pre & post surgery), and Enoxaparin. Susan walked shortly after surgery, and regularly thereafter. Additionally, Susan started physical therapy on the second day of her hospitalization and had two sessions per day. She will be discharged home today, with plans to see her orthopedic surgeon in two weeks. Susan will also start outpatient physical therapy twice a week, with at home exercises she has been instructed to perform daily. Susan has also been instructed to see her primary care provider in the next few weeks.
Susan’s other history is as follows: Ht: 5’4” WT: 225 BP: 126/86 Temp: 98.9 F O2 sats: 99% on RA Pain: 3/10 in her left hip.
Insurance: Medicare Advantage.
PMH: Obesity (BMI 36.9 kg/m2). Tonsillectomy at 11 years of age. Bilateral hip osteoarthritis. Vitamin D deficiency. Depression.
FH: Father deceased, prostate cancer at 82, anxiety, CAD. Mother deceased, Alzheimer’s at 85, HTN, osteoporosis. Son, 42, obesity. Daughter, 37, anxiety.
SH: Bachelors degree in library science. Retired high school librarian. Receives $5,500 a month in combined Social Security and state retirement funds. Married with two children. Husband is a retired police officer. They share a home is in a neighborhood that is being revitalized by the influx of many new young families. The neighborhood borders a nature preserve. There are many food and recreation options, and a full service grocery store just down the street. Susan and her husband usually eat at the local restaurants daily, and eat processed foods at home. Neither enjoys cooking. She does not have a regular exercise routine. No smoking history. Drinks 2 glasses of wine 3-4 times a week with dinner. Two cups of coffee, and two regular sodas per day. Susan and her husband attend a local Unitarian church. Extended family for both Susan and her husband live nearby, within 45 minutes of their home.
Meds: Aspirin 81 mg tab, 1 tab daily by mouth. Ibuprofen 200 mg tab, 2 tabs by mouth every 4-6 hours as needed for pain. Acetaminophen 500 mg tab, 1-2 tabs every 4-6 hours by mouth as needed for pain, no more than 3 grams per day. Enoxaparin 40 mg sc injection, inject sc once daily for 7 days after discharge. Oxycodone 5 mg tab, 1 tab by mouth every 4-6 hours as needed for pain.
Allergies: PCN allergy-hives. No food or environmental allergies.
References
Cianelli, R., Clipper, B., Freeman, R., Goldstein, J., & Wyatt, T. H. (2016). The innovation road map:
A guide for nurse leaders.
Revised 14April2022
