NURS FPX 6207 Assessment 3 Leadership Presentation to Community Stakeholders: Improving Care Transitions and Reducing Readmissions

Introduction

NURS FPX 6207 Assessment 3 With health care ever changing, community stakeholders are key players in improving population health outcomes. Nurse leaders need to be able to present strategic plans responding to local healthcare issues. One of these concerns is the rate of hospital readmission, particularly for older adults with chronic conditions.

This leadership presentation defines a nurse-driven project to enhance care transitions and prevent 30-day hospital readmissions by involving community stakeholders. The aim is to promote interorganization collaboration between hospitals, primary care physicians, long-term care centers, and home health agencies to provide continuity of care.

Background: The Problem of Poor Care Transitions

• Ineffective care transitions are a leading cause of avoidable hospital readmissions. Patients are discharged from the hospital without:
• Clear medication instructions
• Follow-up visits
• Awareness of warning signs
• Community support systems

The outcome? Frustrated patients, burdened families, and greater pressure on healthcare resources.

The Agency for Healthcare Research and Quality (AHRQ) reports that nearly one in five Medicare patients is readmitted within 30 days, frequently as a result of failures in care transitions.

The Role of Nursing Leadership in Care Coordination

Nurses are best suited to fill gaps in care transitions. By influencing leadership, advocacy, and collaboration, nurses can lead system-level changes that eliminate readmissions and enhance patient outcomes.

Nursing Leadership Goals Include:

• Enhancing communication across care settings
• Coordinate follow-up care
• Involving patients and families in discharge planning
• Collaborating with community organizations

Target Audience: Community Stakeholders

For this project, the major community stakeholders are:

Primary care providers: For timely follow-up

Home health nurses and aides: For patient monitoring on an ongoing basis

Long-term care facilities: For post-acute care coordination

Nonprofits and public health departments: To provide social services and education

By involving these partners, we can build an integrated and sustainable care transition model.

Proposed Solution: Transitional Care Nursing Program

Overview

The proposed solution is a nurse-directed Transitional Care Program (TCP) targeting high-risk patients. The program will provide assistance to patients in the initial 30 days following discharge—a critical period when hospital readmission is most probable.

Program Components:

1. Pre-Discharge Planning
   
   • Comprehensive education via teach-back methods
   • Medication reconciliation
   • Follow-up visit scheduling
2. Post-Discharge Follow-Up
   
   • Nurse phone calls within 48 hours
   • In-home or telehealth visits
   • Coordination with specialists and primary care
3. Community Resource Referrals
   
   • Social work involvement
   • Nutrition and transportation services
   • Chronic disease self-management programs

Implementation Strategy

Phase 1: Planning

• Identify high-risk patient groups with EHR data and LACE index
• Involve stakeholders in program development
• Train nurses on transitional care procedure

Phase 2: Pilot Program

• Implement in one hospital unit
• Monitor metrics including readmission, follow-up adherence, and patient satisfaction

Phase 3: Expansion and Sustainability

• Implement to other units and facilities
• Obtain funding via grants and collaborations
• Integrate stakeholder feedback

Expected Outcomes

Additional Benefits:

• Decreased emergency department utilization
• Enhanced provider communication
• Improved patient self-management skills