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Reducing readmissions in programs of all-inclusive care for the elderly through transition of care interventions
Dissertation   Open access

Reducing readmissions in programs of all-inclusive care for the elderly through transition of care interventions

Yvette Rene Banks
Doctor of Nursing Practice (D.N.P.), Drexel University
Dec 2019
DOI:
https://doi.org/10.17918/00000015
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Abstract

Nursing practice Hospitals--Admission and discharge Continuum of care Older People
Twenty percent of older adults age 65 years and older discharged from the hospital are readmitted within 30 days of discharge (Jencks, Williams & Coleman 2009). The readmission rate among the same population is roughly 23% (Segelman et al., 2014). Each year, the estimated cost of avoidable hospital readmissions is roughly $12 billion (Hudali, Robinson and Bhattari 2017). The purpose of this pilot quality improvement project was to evaluate the effectiveness of a transition of care interventions when applied to individuals enrolled in Programs of All-Inclusive Care for the Elderly (PACE). Transition of care interventions are evidence base practice which creates a standard of care with the goal of avoiding and reducing hospital readmissions (Dusek, Harripaul, & Lloyd, 2014). The Promoting Action on Research Implementation in Health Services (PARiHS) was the conceptual model which provided the foundational constructs of the project while the Model for Evidence Base Practice Change guided the implementation of this pilot quality improvement project (Rosswurm and Larrabee, 1999). PACE enrollee's hospital admission data was collected, measured and analyzed to evaluate the effectiveness of the transitional care interventions which are designed to prevent hospital readmissions. In a study of a comparable population, hospital readmissions decreased by 43% when transition of care interventions were applied (Lipani, Holster and Bussey, 2015). Key Words: Programs of all-inclusive care for the elderly, hospital readmissions, transitions of care

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