D117 Care Plan for Transition- Phase

Student Name

Western Governors University 

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name

Date

Overview of the CMS Hospital Readmissions Reduction Program

In 2012, a federal mandate directed the Centers for Medicare and Medicaid Services (CMS) to implement a value-based purchasing program focused on improving patient outcomes by enhancing communication, discharge planning, and care coordination. This program, known as the Hospital Readmissions Reduction Program (HRRP), financially incentivizes hospitals to reduce avoidable readmissions occurring within 30 days of discharge by linking reimbursements to hospital performance metrics (Centers for Medicare & Medicaid Services [CMS], 2023). The primary objective of HRRP is to decrease unnecessary hospital readmissions by encouraging the adoption of evidence-based transitional care strategies that actively engage patients and caregivers during discharge.

CMS monitors hospital readmission rates across six clinical areas: acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty or total knee arthroplasty (THA/TKA). Hospitals with readmission rates exceeding established benchmarks face financial penalties up to 3%. While the penalty may appear modest, it serves as a significant motivator for hospitals to investigate causes of readmissions and improve discharge protocols.

Why Is Transitional Care Planning Vital for Reducing Readmissions?

Unplanned hospital readmissions are often influenced by multiple factors, many of which stem from systemic failures rather than unavoidable disease progression. These include poor inter-provider communication, medication mistakes, inadequate follow-up, and lack of patient education. Feigenbaum et al. (2012) emphasize that missed opportunities in transitional care, such as insufficient medication management and poor coordination among healthcare disciplines, contribute heavily to 30-day readmissions. These findings underscore the critical importance of implementing structured transitional care plans, which, when properly executed, can substantially reduce preventable readmissions.

Elective total hip arthroplasty (THA) is specifically targeted by HRRP, as it allows healthcare providers to anticipate and mitigate post-discharge complications through standardized care protocols. Regardless of whether patients return home or transition to skilled nursing facilities, evidence-based transitional care plans are essential for optimal recovery and readmission prevention.

What Are the Common Clinical Risks and Causes of Readmission Following Total Hip Arthroplasty?

Patients undergoing total hip arthroplasty face several postoperative complications that can result in unplanned readmissions. According to Kurtz et al. (2018), the most common causes include surgical site infections, atrial fibrillation, pulmonary embolism, septicemia, and pneumonia. These risks highlight the necessity for comprehensive patient education, diligent monitoring, and prompt follow-up care during the transition from hospital to home.

Patient Case Scenario: Susan

Susan is a 68-year-old female with advanced osteoarthritis scheduled for elective total hip arthroplasty. She presents with multiple comorbidities, including obesity (BMI 36.9 kg/m²) and depression, which elevate her risk of postoperative complications and subsequent readmission. This case illustrates the complex interplay of health factors necessitating a thorough transitional care plan.

What Role Does the APRN Play in Preventing 30-Day Readmission?

The Advanced Registered Nurse Practitioner (APRN) is central to coordinating Susan’s discharge and minimizing her readmission risk. A key aspect is infection prevention, including ensuring adherence to her prescribed antibiotic regimen. Given Susan’s penicillin allergy, clindamycin is used as an alternative; however, the APRN must educate Susan about the potential for Clostridioides difficile infection and instruct her to report symptoms such as persistent or bloody diarrhea promptly.

Furthermore, the APRN must provide explicit guidance on surgical site care and emphasize the importance of promptly reporting signs of infection, such as redness, swelling, warmth, or drainage. Continuity of care is maintained by directing Susan to communicate post-discharge concerns directly with her orthopedic surgeon.

How Should Medication Management and Anticoagulation Be Managed?

Effective medication reconciliation is crucial to avoid adverse drug events and ensure continuity of care. Susan should receive a comprehensive medication list detailing drug names, doses, schedules, and indications. This list must be shared with her and her primary care provider.

To reduce thromboembolic risk, Susan’s discharge plan includes a prophylactic anticoagulation regimen involving low-dose aspirin, injectable enoxaparin for the prescribed duration, and encouragement of regular ambulation. Pain control employs a multimodal approach combining NSAIDs, opioids when necessary, and scheduled acetaminophen to facilitate mobility and prevent complications associated with immobility.

What Nutritional and Weight Management Approaches Are Recommended?

Given Susan’s obesity, nutritional support is vital to her recovery and joint health. Initially, a soft, bland diet is advised, progressing as tolerated. A balanced diet rich in protein supports wound healing and tissue repair. Long-term, the primary care provider should oversee sustainable weight management to alleviate joint stress and prevent further degeneration.

How Can Mobility, Physical Therapy, and Home Safety Be Optimized?

Preventing injury to the new joint requires strict adherence to hip precautions learned during inpatient physical therapy. Susan and her family must be educated on safe movements and necessary home modifications to minimize fall risks. These modifications include decluttering, installing raised toilet seats, using shower chairs, and employing pillows or bed risers.

Durable medical equipment such as walkers and continuous passive motion devices should be provided prior to discharge. Outpatient physical therapy appointments should be scheduled, and transportation arranged to ensure compliance.

How Can Pulmonary Complications Be Prevented?

Pulmonary complications after THA, such as atelectasis and pneumonia, are preventable with proper care. Susan should be encouraged to use incentive spirometry regularly, perform deep breathing and coughing exercises, maintain adequate hydration, and ambulate frequently. Written instructions should be clear and easily understood to promote adherence.

How Does Multidisciplinary Discharge Planning and Social Support Influence Readmission Risk?

Before discharge, Susan should undergo evaluation by a multidisciplinary team including physical therapy, occupational therapy, and social work to ensure home safety. Addressing social determinants—such as access to transportation, medication procurement, grocery shopping, and family support—is critical, as insufficient logistical support markedly raises the risk of readmission.

How Was the Care Plan Reviewed and Enhanced?

This transitional care plan was reviewed by MaryEllen Kopp, APRN, a specialized postsurgical cardiac advanced practice provider. She emphasized the importance of multidisciplinary discharge clearance, vigilant monitoring for Clostridioides difficile infection, and thorough education about wound infection symptoms. Her input enhanced the clinical applicability and quality of the care plan, guiding ongoing development of this academic initiative.

References

Centers for Medicare & Medicaid Services. (2023). Hospital readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program

Feigenbaum, P., Neuwirth, E., Trowbridge, L., Teplitsky, S., Barnes, C., Fireman, E., Dorman, J., & Bellows, J. (2012). Factors contributing to all-cause 30-day readmissions: A structured case series across 18 hospitals. Medical Care, 50(7), 599–605. https://journals.lww.com/lwwmedicalcare/Abstract/2012/07000/Factors_Contributing_to_All_cause_30_day.7.aspx

Kurtz, S., Lau, E., Ong, K., Adler, E., Kolisek, F., & Manley, M. (2016). Which hospital and clinical factors drive 30- and 90-day readmission after total knee arthroplasty? The Journal of Arthroplasty, 31(10), 2099–2107. https://www.sciencedirect.com/science/article/pii/S0883540316300043

Phruetthiphat, O., Otero, J. E., Zampogna, B., Vasta, S., Gao, Y., & Callaghan, J. J. (2020). Predictors for readmission following primary total hip and total knee arthroplasty. Journal of Orthopaedic Surgery, 28(3). https://journals.sagepub.com/doi/10.1177/2309499020959160