Introduction
Outreach programs led by a registered nurse are known to have a significant impact on the quality of care and health outcomes of patients (Toyce, et al. 2015). Nurses involved in post-discharge care such as home safety evaluation, medication compliance, and patient education have a positive impact on patient outcomes (Toyce, et al. 2015). Most patients do not follow instructions laid by the healthcare professional post-discharge which leads to non-compliance and readmission. This problem can be solved by a nurse-led outreach program that helps patients in various activities at home, thus improving health outcomes and reduced readmission rates. Nurses provide the best care plans for patients after discharge in order to facilitate and improve overall quality of care of patients (Toyce, et al. 2015). Readmission, non-compliance, medication errors, medication side-effects/adverse events, falls, lack of home safety, and compromised health and medical facilities have been a major issue for discharged patients (Boyd, et al. 2014 and(Toyce, et al. 2015).
An outreach program by a healthcare professional or registered nurse (RN) is known to have a positive impact on the health outcome and readmission rate (Storch, et al. 2014). The outreach program should be framed and developed based on current evidence, nursing practice and patient requirement (Boyd, et al. 2014 and Toyce, et al. 2015).
Background
Readmission and comprised healthcare services and clinical outcomes are the major issues observed among patients post-discharge. Based on current evidence, a well-defined action plan led by an RN on an outreach program to address potential issues in a systematic and organized manner can improvise quality of care and health outcomes in patients (Tourangeau, et al. 2014). This paper provides an overview on a RN led outreach program and its impacts on patient outcomes and rate of readmission in the next 6 months.
Overview of the John Hopkins Nursing Evidence-Based Practice Process
The Johns Hopkins Nursing Center for Evidence-Based Practice is one of the premier and renowned practice processed for nurses which inculcates leadership, nest practices, training and support to nurses (Barbara et al. 2012). The department of nursing offers a comprehensive view on the evidence-based practice with the help of books, tools, models, and consultation. The most widely adopted and used is the Johns Hopkins Nursing evidence-based practice model (JHNEBP) and guidelines (Figure 1) (Barbara et al. 2012). The model consist of three backbones: practice, education, and research. However, the model can be utilized for both research and non-research evidence (Barbara et al. 2012). The JHNEBP model comprises of three vital phases: Identification, systematic review, and translation. The first phase consist of identification of a problem and framing the question. The second phase comprises of review and synthesis of evidence. The third and final phase comprises of translation. All the phases are synthesized and review by a team of evidence-based personnel who would determine the feasibility and implementation of practice changes. The third phase of the model is incorporated after this step wherein the recommendations from evidence are implemented in practice as a pilot study based on the measurement of outcomes and dissemination of findings (Barbara et al. 2012).
Nurses should use this model as a guide to facilitate change
Nurse leaders and nurse practitioners should incorporate, adopt, and implement the JHNEBP model in order to provide the best practice based on evidence (Barbara et al. 2012). The model not only facilitates the improvement of quality care but also provides the best framework for nurses to improvise the health outcomes for patients. Nurses can facilitate change in practice by implementing best practice methods, guidelines, and protocols for the benefit of the healthcare system (Barbara et al. 2012).
Inter-professional Team: The outreach program would comprise of an inter-professional team which would include a Head nurse, in-charge nurse, pharmacist, healthcare professional, para-medical personnel, physician, and caregiver (relative). The physician, in-charge nurse, and caregiver would be immediate point-of-contact for the patient (Yu, et al. 2016). The head nurse would act as a co-ordinator for the entire program and would ensure the quality delivery of the services to each and every patient (Yu, et al. 2016).
EBP Question: Elderly patients often face medication errors due to polypharmacy and it is important to address the geriatric population in this case. The intervention for medication errors and other issues related to home-care include patient education and guidance. Nurse interventions would involve effective communication and patient-centric care. The main alterative to the conventional intervention is an outreach program that comprises of an inter-professional team that would assist the patient. The main outcome of the evidence-based practice is reduce readmission rates and improved health outcomes among geriatric patients in the next 6 months post-discharge (Reifler, & Bruce. 2014).
Scope of the EBP: Readmission rates of the geriatric population has increased in the past decade owing to unplanned home safety measures and ineffective communication plans by nursing professionals. In the US, nearly 3 million elderly patients are known to be readmitted to nursing homes due to unplanned discharge protocols, poverty, and ineffective safety measures. The readmission of elderly patients accounts for over $10 million annually with an estimated cost of $50 million by 2020. Nurses and healthcare professionals consider this as a burden since it increases healthcare cost (Iloabuchi, et al. 2014).
Responsibility of Team Members: Each member of the outreach program are of prime importance since most of the responsibilities are shared and inter-related in order to provide best healthcare service to the patient. The nurse leader would co-ordinate the action plan with the in-charge nurse and physician. The nurse leader would be directly responsible for the overall outreach program with respect to services provided, communication plans, implementation strategies, and strategic health outcomes. The physician and in-charge nurse would monitor the patient’s health condition on a regular basis and in the event of an emergency, they would take the best action plan. The in-charge nurse would report to the physician on any abnormal behaviours/reports to the physician which would be forwarded to the head or nurse leader. The pharmacist would play a key role in providing medications to the team and also co-ordinate with team members on the supply chain and demand/supply analytics of certain drugs. Lastly, the caregiver is a direct contact to the patient who would provide timely reports to the head nurse and in-charge nurse (Van der Ven, et al. 2015).
Methodology and evidence appraisal: PUBMED, Google scholar, and the COCHRANE library were utilized to search evidence associated with readmission, outreach programs, and nurse interventions. Most of the evidence were from peer-reviewed journals, guidelines, and scientific statements. The current study is a qualitative research which explores underlying opinions and reasons on outreach programs. The key strengths of the study are the wealth of qualitative information gathered through primary research, organized content, precise and reliable data, easy to analyse, and generalized findings (Pautasso, M. 2013).
Current Evidence: A recent national-level outreach program for the elderly in Asia was found to be effective in reducing the rate of readmissions (Verma, & Khanna, 2013). Outreach programs have improved health outcomes of the homeless and elderly by effective nursing interventions (Brown, et al. 2013). The physiological and mental health of elderly patients are known to improve by implementing nurse-based outreach programs (Qiu, et al. 2010). Lastly, outreach programs are also known to reduce the risk of medication errors and other home-related risks among elderly patients (Aggarwal, & Mosca, 2010).
Recommendations for Change Based on Evidence
Based on current evidence, nurse education and training on the treatment and management of elderly patients in outreach programs is highly recommended (Niven, et al. 2014). Trained and experienced staff could only help in providing high quality care to patients (Kayama, et al. 2014). An inter-professional team is recommended for the successful implementation of an outreach program. The inter-professional team should comprise of various members from the health, para-medical, psychological, pharmacy, and medicine background (Kayama, et al. 2014). Nurse leaders should develop effective communication plans and strategies effective models and plans to address the needs of elderly patients (Kayama, et al. 2014). The key objective of the outreach program is to reduce the rate of readmission and improve health outcomes of patients in a span of 6 months. Some of the issues that should be addressed by nurse leaders in the outreach program include medication errors, compliance by patients, home safety practices, patient and caregiver education, communication plans, and adaptive emergency protocols (Kayama, et al. 2014).
Action Plan
The outreach program would comprise of an organized plan that would include the following steps: (a) Formation of an inter-professional team: This step is critical since it would impact the outcome of the program and should only include trained and experienced staff (b) Addressing issues: By addressing and resolving issues of home-care facilities would have a positive impact on the expected outcome (c) Utilizing models: In order to provide an effective and practical framework, models and guidelines from evidence and theorist would be implemented in the pilot study (d) Outcome measurement and assessment: The outcomes of the study would have to be assessed by qualified and experienced personnel who would provide necessary recommendations (Partapuri, Steinglass, & Sequeira, 2012).
The implementation of the program would take 2 months considering the infrastructure development, recruitment of team members, and patient assessment (Lapierre, et al. 2011). The overall study would be completed in 8 months, considering the assessment of 6 month post-discharge outreach program outcome benefits. All outcomes would have to be precisely measured and assessed by a team of experts (Lapierre, et al. 2011). All the reports that would be generated during evaluation would be discussed with the inter-professional team (Reifler, & Bruce. 2014). Some of the key issues that would be addressed during the outcome assessment include patient well-being, health improvement, rate of readmission, home safety improvement, risk of medication errors, clinical outcomes, quality care of patients, risk-benefit ratio of intervention, delay of expected outcome, and compliance issues pertaining to patient welfare (Reifler, & Bruce. 2014 and Lapierre, et al. 2011)
Evaluating Outcomes and Reporting Outcomes
The key expected outcomes of the study include improved health outcomes and reduced rate of readmissions of elderly patients. The outcomes would be measured by assessing the rate of medication errors, falls, non-compliance, home safety improvement, and clinical improvement of the patient (Harrison, et al. 2014). The outcomes would be reported to the key stakeholders with the help of an organized communication plan such as posters, newsletters, manuals, and comprehensive case reports that can be viewed in digital and paper formats. The outcomes would be communicated to patients as well (Harrison, et al. 2014).
Expansion of the action plan and outreach program
The success of the program would be appreciated by various departments and it could be expanded to other interdisciplinary departments (Toye, et al. 2015). The expansion of the outreach program to other departments would include a series of evaluation and strategies to implement and execute the program. Some of the key factors that should be addressed prior to the expansion of the outreach program include: (a) Viability of the program: The usefulness and effectiveness of the program and its viability should be addressed prior to execution. (b) Assessment of target population and department: Not all outreach programs are effective and productive for all population and department types (Toye, et al. 2015) Prior to implementing the program, consultation from key stakeholders is recommended and (c) Eligibility criteria and current status: In order to expand the program under a department, eligibility criteria should be developed by the same inter-professional team along with a status and background check for the intervention and population (Toye, et al. 2015)
Dissemination of findings
The findings of the outreach program would be communicated through both, digital and print-based platforms (Toye, et al. 2015). A dedicated website would be developed or key findings of the study would be published on a high impact website. The key stakeholders of the study would be provided brochure, newsletters, manuals, and reports on both digital and print platforms. Social media maybe utilized in accordance to regulations and policies for data sharing. For external audiences, the social media and website platform would form key tools to communicate the findings of the study. Literature on the same would be published in a high impact journal and other educational websites (Abdullah, et al. 2014).
Conclusion
Elderly patients often face many health problems at their homes and thus the implementation of a nurse-led outreach program was considered essential. The implementation of such programs has improved the health outcome and recued the rate of readmissions by a significant extent. The study addressed the 3 cornerstones of the JHNEBP model, i.e. nurses utilized information from evidence and implanted into practice by means of education and training. The overall study had a positive impact on the health outcome of elderly patients.
Figure 1. The Johns Hopkins Nursing Evidence-Based Practice Conceptual Model (Barbara et al. 2012)
References
Abdullah, G., Rossy, D., Ploeg, J., Davies, B., Higuchi, K., Sikora, L., & Stacey, D. (2014).
Measuring the Effectiveness of Mentoring as a Knowledge Translation Intervention for Implementing Empirical Evidence: A Systematic Review. Worldviews on Evidence-Based Nursing, 11(5), 284–300. http://doi.org/10.1111/wvn.12060
Aggarwal, B., & Mosca, L. (2010). Lifestyle and Psychosocial Risk Factors Predict Non-
adherence to Medication. Annals of Behavioral Medicine : A Publication of the Society of Behavioral Medicine, 40(2), 228–233. http://doi.org/10.1007/s12160-010-9212-6
Barbara, L. et al. (2012). An Evidence-based Approach to Decrease Early Post-operative
Urinary Retention Following Urogynecologic Surgery. Urol Nurs. 2012;32(5):260-264.
Brown, R. T., Thomas, M. L., Cutler, D. F., & Hinderlie, M. (2013). Meeting the Housing
and Care Needs of Older Homeless Adults: A Permanent Supportive Housing Program Targeting Homeless Elders. Seniors Housing & Care Journal, 21(1), 126–135.
Boyd M, Armstrong D, Parker J, Pilcher C, Zhou L, McKenzie-Green B, Connolly MJ.
(2014). Do gerontology nurse specialists make a difference in hospitalization of long-term care residents? Results of a randomized comparison trial. J Am Geriatr Soc. 2014 Oct;62(10):1962-7. doi: 10.1111/jgs.13022. Epub 2014 Oct 3.
Harrison JD, Auerbach AD, Quinn K, Kynoch E, Mourad M. (2014). Assessing the impact of
nurse post-discharge telephone calls on 30-day hospital readmission rates. J Gen Intern Med. 2014 Nov;29(11):1519-25. doi: 10.1007/s11606-014-2954-2.
Iloabuchi TC, Mi D, Tu W, Counsell SR. (2014). Risk factors for early hospital readmission
in low-income elderly adults. J Am Geriatr Soc. 2014 Mar;62(3):489-94. doi: 10.1111/jgs.12688. Epub 2014 Feb 27.
Kayama, M., Kido, Y., Setoya, N., Tsunoda, A., Matsunaga, A., Kikkawa, T., Ito, J.
(2014). Community outreach for patients who have difficulties in maintaining contact with mental health services: longitudinal retrospective study of the Japanese outreach model project. BMC Psychiatry, 14, 311. http://doi.org/10.1186/s12888-014-0311-y
Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., the
International Research Group for Suicide among the Elderly. (2011). A Systematic Review of Elderly Suicide Prevention Programs. Crisis, 32(2), 88–98.
Niven DJ, Bastos JF, Stelfox HT. (2014). Critical care transition programs and the risk of
readmission or death after discharge from an ICU: a systematic review and meta-analysis. Crit Care Med. 2014 Jan;42(1):179-87. doi: 10.1097/CCM.0b013e3182a272c0.
Partapuri, T., Steinglass, R., & Sequeira, J. (2012). Integrated Delivery of Health Services
During Outreach Visits: A Literature Review of Program Experience Through a Routine Immunization Lens. The Journal of Infectious Diseases, 205. S20–S27.
Pautasso, M. (2013). Ten Simple Rules for Writing a Literature Review. PLoS Computational
Biology, 9(7), e1003149. http://doi.org/10.1371/journal.pcbi.1003149
Qiu, W. Q., Dean, M., Liu, T., George, L., Gann, M., Cohen, J., & Bruce, M. L. (2010).
Physical and Mental Health of the Homebound Elderly: An Overlooked Population. Journal of the American Geriatrics Society, 58(12), 2423–2428.
Reifler, B. V., & Bruce, M. L. (2014). Home-Based Mental Health Services for Older Adults:
A Review of Ten Model Programs. The American Journal of Geriatric Psychiatry : Official Journal of the American Association for Geriatric Psychiatry, 22(3), 241–247. http://doi.org/10.1016/j.jagp.2012.12.002
Storch J, Curry CG, Stevenson L, Macdonald M, Lang A. (2014). Ethics and safety in home
care: perspectives on home support workers. Nurs Leadersh (Tor Ont). 2014 Mar;27(1):76-96.
Tourangeau A, Patterson E, Rowe A, Saari M, Thomson H, MacDonald G, Cranley L,
Squires M. (2014). Factors influencing home care nurse intention to remain employed. J Nurs Manag. 2014 Nov;22(8):1015-26. doi: 10.1111/jonm.12104. Epub 2013 Jun 12.
Toye, C., Moorin, R., Slatyer, S., Aoun, S. M., Parsons, R., Hegney, D., Hill, K. D.
(2015). Protocol for a randomised controlled trial of an outreach support program for family carers of older people discharged from hospital. BMC Geriatrics, 15, 70. http://doi.org/10.1186/s12877-015-0065-5
Van der Ven MJ, Schoon Y, Olde Rikkert MG. (2015). [Unplanned readmissions of frail
elderly patients: a retrospective analysis of admissions in a teaching hospital]. Ned Tijdschr Geneeskd. 2015;159:A9211
Verma, R., & Khanna, P. (2013). National Program of Health-Care for the Elderly in India: A
Hope for Healthy Ageing. International Journal of Preventive Medicine, 4(10), 1103–1107.
Yu CH, Halapy H, Kaplan D, Brydges R, Hall S, Wong R. (2016). Effects of a Longitudinal
Interprofessional Educational Outreach Program on Collaboration. J Contin Educ Health Prof. 2016 Winter;36(1):24-31. doi: 10.1097/CEH.0000000000000020.
