Capella FPX 4005 Assessment 3
Student Name
Capella University
NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations
Prof. Name
Date
Interdisciplinary Plan Proposal
This proposal aims to reduce hospital readmissions for heart failure and diabetes patients at Maplewood Medical Center by implementing a structured discharge education and follow-up program. By enhancing interdisciplinary collaboration among nursing, pharmacy, case management, and social services, the initiative will improve patient adherence to post-discharge care and optimize resource utilization. Successful implementation will lead to better patient outcomes, reduced readmission rates, and improved operational efficiency.
Objective
This interdisciplinary plan aims to implement a structured discharge education and follow-up program to reduce hospital readmissions for heart failure and diabetes patients at Maplewood Medical Center. By improving care coordination among nursing, pharmacy, and case management, the initiative will enhance patient adherence, optimize medication management, and strengthen community-based support. The plan will help fewer patients return to the hospital. Patients will feel satisfied with their care. The hospital authorities will use resources more wisely. Effective leadership and communication are essential for successful implementation (Jankelová & Joniaková, 2021).
Questions and Predictions
- How will implementing a structured discharge education and follow-up program impact patient adherence to post-discharge care?
Initially, adherence can improve modestly as patients adjust to the new process. However, adherence rates are expected to increase significantly within six months with consistent reinforcement and interdisciplinary collaboration.
- What challenges might arise in coordinating efforts between nursing, pharmacy, case management, and social services?
Communication gaps and workflow misalignment may initially occur. However, teamwork and coordination will improve over time through interprofessional rounds and standardized protocols.
- How much will readmission rates decrease within the first year of implementation?
A conservative estimate is a 10–15% reduction in readmissions for heart failure and diabetes patients within the first year, with further reductions as the program becomes more refined.
- What effect will this plan have on patient satisfaction scores?
Patient satisfaction scores are expected to rise as patients receive more comprehensive discharge planning, improving their confidence in managing their conditions at home.
- Will this initiative reduce hospital costs related to readmissions?
Yes, by decreasing readmissions, the hospital will save costs associated with repeated inpatient stays, allowing resources to be allocated more efficiently.
Change Theories and Leadership Strategies
Kotter’s 8-Step Change Model provides a structured plan for implementing interdisciplinary initiatives at Maplewood Medical Center to reduce patient readmissions. This model focuses on acting quickly, building a strong team, and sharing a clear goal (Miles et al., 2023). Transformational leadership inspire and encourage healthcare teams to work together toward a common goal. This fits well with Kotter’s model. Transformational leaders help their teams work together and take responsibility. They listen, share ideas, and support learning and growth (Jankelová & Joniaková, 2021).
This leadership approach will help create a culture of interdisciplinary collaboration, ensuring that team members remain engaged and committed to reducing readmission rates through improved discharge planning and Post-hospital support (Centers for Medicare & Medicaid Services (CMS), 2024). Establishing urgency by presenting data on readmission rates and their financial and patient care consequences will help secure buy-in from stakeholders. Forming a guiding coalition, including nursing, pharmacy, case management, and social services, ensures diverse expertise in tackling the root causes of readmissions. Clear and consistent communication of the project’s benefits will foster engagement and collaboration at Maplewood Medical Center.
Team Collaboration Strategy
The implementation of the plan to reduce patient readmissions at Maplewood Medical Center will require a structured approach with clear roles and responsibilities for each team member. The case management team will identify high-risk patients before discharge and ensure they receive appropriate follow-up care. Nurses will educate patients on medication adherence, lifestyle modifications, and self-care management before discharge (Morris, 2020). Pharmacists will conduct medication reconciliation and address potential drug interactions to prevent complications that could lead to readmission.
Social workers will assist in coordinating home health services and ensuring patients have access to necessary resources, such as transportation and financial assistance. Physicians will oversee the discharge process, ensuring care plans align with best practices and patient needs. Follow-up calls and home visits will be scheduled within 48 hours post-discharge to address emerging concerns and reinforce self-care strategies.
A structured interdisciplinary team meeting approach will be implemented to facilitate collaboration. Weekly case review meetings will be held, where team members discuss patient progress, identify potential barriers to successful recovery, and adjust care plans accordingly. Using a shared electronic health record (EHR) system will improve communication and ensure that all team members have real-time access to patient data (Dayama et al., 2024). A collaborative problem-solving approach, such as structured huddles before patient discharges, will also foster proactive discussions and improve patient outcomes. By promoting open communication, shared decision-making, and accountability, this collaboration model will enhance efficiency and drive the success of the readmission reduction initiative.
Required Organizational Resources
Implementing the readmission reduction plan at Maplewood Medical Center requires staffing, equipment, and access to existing resources. Staffing needs include a full-time case manager, estimated at $80,000 annually (Monti, 2020), additional nursing hours for patient education, and pharmacists for medication reconciliation. Nurses will dedicate 10% more of their shift time to patient education, costing approximately $8,901 per nurse annually. For a staff of 50, this equates to an additional $445,050 per year (Morris, 2020). These costs may be offset by reducing readmission rates and associated penalties.
Essential equipment includes patient education materials, telehealth software, and expanded electronic health record (EHR) access. A study of 391 Medicaid-focused nursing homes found that 76% used EHRs, with each incremental increase in use linked to a 0.12% profit rise (Dayama et al., 2024). If telehealth is not yet integrated, acquiring a platform may require $60,000 in licensing and IT support (Zachrison et al., 2021). Seamless access to inpatient, outpatient, and home health services is also critical for effective care transitions.
Without these interventions, continued high readmission rates could have significant financial consequences. The Hospital Readmission Reduction Program (HRRP) fines hospitals up to 3% of Medicare payments for excessive readmissions (Centers for Medicare & Medicaid Services [CMS], 2024). By strategically investing in staffing and technology, Maplewood Medical Center can enhance patient outcomes, improve efficiency, and mitigate financial penalties associated with preventable readmissions.
Conclusion
This plan will help patients stay healthy after leaving the hospital. It will bring nurses, pharmacists, case managers, and social workers together to provide better care. With clear steps and teamwork, fewer patients will need to return to the hospital, saving money and improving patient lives. In the end, everyone benefits, including patients, families, and the hospital.
References
Centers for Medicare & Medicaid Services (CMS). (2024, September 10). Hospital readmissions reduction program (HRRP). Www.cms.gov. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp
Dayama, N., Pradhan, R., Davlyatov, G., & Maldonado, R. W. (2024). Electronic health record implementation enhances financial performance in high Medicaid nursing homes. Journal of Multidisciplinary Healthcare, Volume 17, 2577–2589. https://doi.org/10.2147/jmdh.s457420
Capella FPX 4005 Assessment 3
Jankelová, N., & Joniaková, Z. (2021). Communication skills and transformational leadership style of first-line nurse managers in relation to job satisfaction of nurses and moderators of this relationship. Healthcare, 9(3), 1–19. NCBI. https://doi.org/10.3390/healthcare9030346
Miles, M. C., Richardson, K. M., Wolfe, R., Hairston, K., Cleveland, M., Kelly, C., Lippert, J., Mastandrea, N., & Pruitt, Z. (2023). Using Kotter’s change management framework to redesign departmental GME recruitment. Journal of Graduate Medical Education, 15(1), 98–104. https://doi.org/10.4300/JGME-D-22-00191.1
Monti, J. (2020, June 3). RN case manager salary and job outlook – nursejournal.org. NurseJournal. https://nursejournal.org/careers/nurse-case-management/salary/
Morris, J. (2020, September 18). Registered nurse (RN) salary and career overview | nursejournal.org. NurseJournal. https://nursejournal.org/registered-nursing/rn-salary/
Zachrison, K. S., Richard, J. V., & Mehrotra, A. (2021). Paying for telemedicine in smaller rural hospitals: Extending the technology to those who benefit most. JAMA Health Forum, 2(8), e211570–e211570. https://doi.org/10.1001/jamahealthforum.2021.1570