NHS FPX 6008 Assessment 2 Needs Analysis for Change

Name

Capella university

NHS-FPX 6008 Economics and Decision Making in Health Care

Prof. Name

Date

Needs Analysis for Change

Hospital readmissions are a major contributor to excess healthcare costs. Although they affect all groups of patients, this is worse in populations of low-income living in Detroit, Michigan, with limited access to healthcare after being discharged from the hospital. In this paper, the author explores the financial implications of hospital readmissions to healthcare institutions, practitioners, and the community, with a special focus on the social determinants of the problem. Using research-based evidence, it discusses the reasons for handling this issue, defines the existing gaps, and analyses the effects and possibilities of development from the proposed measures to tackle readmissions and ensure fairness in healthcare provision.

Healthcare Economic Issue, Impact, Rationale, and Gap

Hospital readmissions continue to be a concern in Detroit, Michigan, and more so among the low-income and the underprivileged. This community’s issues are mainly rooted in poverty, accounting for 33.8% (Barker et al., 2023), and healthcare inaccessibility. Hospitalization brings a lot of readmissions my way, which divert my concentration from early intervention and discharge planning to complications resulting from non-compliance with medication regimens, uncontrolled diseases, and missed appointments. This aggravates nurses’ workload, leading to burnout and low job satisfaction among colleagues.

For my organization, readmissions lead to fines under Medicare’s Hospital Readmissions Reduction Program (HRRP) (Yang et al., 2022), which reduces money for staff training and enhances the quality of care. Low-income and minorities, including Detroit’s population, suffer from increased health disparities because of poor post-discharge support and health illiteracy. Clinically, it is not healthy for patients to be admitted severally and repeatedly within a short period as this affects their social fabric and gaps the field of healthcare further in terms of cost and deservingness.

Hospital readmissions are so sought after because they correlate with patients, hospitals, and sustainability in the healthcare sector. Many people, including myself, have experienced the patterns of seeing patients being discharged without proper follow-up care only to come back with preventive complications. Yang et al. (2022) also noted that hospital readmissions add more financial burdens to the already scant resources, making hospitals financially poor through Medicare penalties. Moreover, poor accessibility of health care for the deprived sections of the population is the underlined inequity.

This helps enhance care delivery continuity, decreasing costs and ensuring all clients have all that is needed to recover. For Detroit, Michigan, the specific gap that falls under hospital readmissions and follow-up care includes poor transitional care and limited follow-up care (Dhaliwal & Dang, 2024), especially for low-income patients with multiple comorbidities. Lack of continuity in care processes, low levels of patient information, and poor patterns of health access also contribute to the problem since patients do not receive adequate preparedness for their health after discharge. Mitigating this gap through transitional care plans, such as better discharge and follow-up care and community-located potential healthy assets, is essential to lowering readmissions and advancing health equality.

Socioeconomic or Diversity Disparities Related to the Issue

Hospital readmissions disproportionately impact low-income and minority populations in Detroit, Michigan, due to socioeconomic and diversity disparities. Most of the Detroit population lacks adequate healthcare provisions since the poverty rate is high at 33.8% (Barker et al., 2023). In addition, vulnerable groups suffer from a greater number of chronic diseases, including diabetes and hypertension. These factors also make a patient a candidate for re-admission, as people from these communities rarely have the means, knowledge, and family support to effectively take care of themselves after being discharged from a hospital.

The nature of these disparities and the possible strategies for decreasing them indicate the need for more developed community health programs, enhanced patient awareness, and better access to primary care and other transitional services. Such evidence-based interventions, including transitional care models focusing on care coordination and follow-up services, have reduced readmissions in the underserved populations (Pugh et al., 2021). In efforts to address them in Detroit, it is important to enhance patient’s health and decrease hospital readmission to achieve the goal of health equity.

Evidence-Based Sources and Hospital Readmissions

Several evidence-based sources prove that hospital readmission is a global problem in the health sector. For instance:

• According to Rajput (2024), hospital readmissions are a significant threat to healthcare and a common pattern often correlated with patients’ undesirable outcomes and increased healthcare costs. They show poor care during the first admission, poor evaluation before discharge, and no follow-up after discharge. Therefore, the authors stress the importance of solving this issue through proper nursing actions.
• As it was learned from CMS’s HRRP initiative, it is crucial for organizations subjected to limited financial penalties to reduce healthcare readmissions. The resource by Psotka et al. (2020) highlights the urgency of addressing hospital readmissions due to the significant economic implications and potential negative impact on patient outcomes. 
• Another resource focuses on hospital readmissions by stressing the need to work on care transitions. The resource encourages the enhancement of the utilization frequency of underemployed processes, for instance, patient participation in discharge planning, community support, and bridging staff for post-discharge care (Pugh et al., 2021).
• Finally, the resource by Dhaliwal and Dang (2024) focuses on the lack of readmitting a hospital, emphasizing that it harms patients’ health and trust in the medical center and is costly not only for patients but also for institutions. Its main emerging point is the need to enhance resource management for far less money, emphasizing the prevention of extramural adverse events through better patient discharge planning, increased patient awareness, and post-discharge management.

Opportunities and Predicted Outcomes of the Change Plan 

The proposed change involves initiating a large-scale transitional care program that includes a discharge plan, follow-up care, patient education, and cooperation with community health services (Pugh et al., 2021). This includes developing individualized care plans for high-risk patients, ensuring follow-up appointments, and offering patients transportation services and health literacy programs. Hospitals would also spend money on staff training to enhance care organization and communication and minimize disintegration during the transition from hospital to home.

Implementing this transitional care program will significantly reduce hospital readmissions, particularly among high-risk and low-income populations in Detroit, Michigan. Better coordination of hospitals, out-of-pocket services, and community health programs will close the gaps in care transitions and equip the patient with all the requirements for post-discharge health management (Khatri et al., 2023). It will also result in fewer readmissions, reduce Medicare penalties under HRRP, and allow hospitals to get more productive resources for staff development and better delivery models.

The changes proposed would result in improved patient care, fewer complications, fewer readmissions, and a better quality of life. Education and teaching materials after discharging patients would help them cope with their chronic illnesses instead of frequenting the emergency rooms or urgent care centers, saving on expensive out-of-pocket expenses (Rajput, 2024). The decrease in readmission rates will save the organization money from penalties and increase the hospital’s image and patient satisfaction. This could lead to an improved patient base, funding, and more openings for further investment in more care programs and services in the community.

Conclusion

Therefore, it is indispensable to focus on the problem of preventing hospital readmissions, especially for patients in deprived areas like Detroit, Michigan. It can be concluded that through better discharge planning, follow-up care, and increased cooperation with community resources, patients and healthcare organizations would benefit from a sophisticated transitional care plan. These reduced readmissions will enhance health, lower penalties, and create new opportunities for the growth of the hospitals. Therefore, this approach will increase the usage of already limited healthcare resources among communities struggling most with limited accessibility in the long run.

References

Barker, E., Hu, Dr. L., Alaswad , H., Fleming, O., & Klammer, S. (2023). Detroit economic indicators report. Detroitmi.gov.https://detroitmi.gov/sites/detroitmi.localhost/files/2024-04/Q2%202023%20Economic%20Indicators%20Report.pdf 

Dhaliwal, J. S., & Dang, A. K. (2024). Reducing hospital readmissions. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK606114/

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09718-8 

NHS FPX 6008 Assessment 2 Needs Analysis for Change

Psotka, M. A., Fonarow, G. C., Allen, L. A., Joynt Maddox, K. E., Fiuzat, M., Heidenreich, P., Hernandez, A. F., Konstam, M. A., Yancy, C. W., & O’Connor, C. M. (2020). The hospital readmissions reduction program. JACC: Heart Failure, 8(1), 1–11. https://doi.org/10.1016/j.jchf.2019.07.012 

Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence-based processes to prevent readmissions: More is better, a ten-site observational study. BioMed Central Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06193-x

Rajput, M. (2024). The role of nursing in reducing hospital readmissions: A review. African Journal of Biomedical Research, 27, 601–604. https://doi.org/10.53555/ajbr.v27i1s.1529 

Yang, Z., Huckfeldt, P., Escarce, J. J., Sood, N., Nuckols, T., & Popescu, I. (2022). Did the Hospital Readmissions Reduction Program reduce readmissions without hurting patient outcomes at high dual-proportion hospitals prior to stratification? INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 59, 004695802110648. https://doi.org/10.1177/00469580211064836