Week 4 literature review

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After identifying the articles to be used in your literature review, conduct a critical analysis of each article and summarize the findings. The literature you choose should support your proposed


Background and Introduction

Diana Aranda

Denver College of Nursing


Instructor’s Name: Sharon Bator

October 22, 2023

Background and Introduction

Nursing education and healthcare practice issues prompted the research paper topic “Hospital readmission within 60 days after discharge to homecare”. Hospital readmissions are a major issue for older patients with chronic conditions transitioning to home care, affecting patient well-being and healthcare costs. This topic sheds light on hospital readmissions within 60 days of homecare discharge.

 Hospital readmissions are an issue of paramount importance in global healthcare systems. Healthcare quality and costs are affected by them. After discharge, patients who return to the hospital raise concerns about their health, initial care, and home care. This is particularly important for older, chronically ill persons with complex medical demands. According to Chen et al. (2020), hospital readmissions in this group are difficult and require further study.

The characteristics of this study’s organizations are diverse and range from hospitals to home care agencies. Medical staff, nurses, home health aides, and family caregivers affect care quality and readmission during the hospital-to-homecare transition. The hospital-to-homecare transfer necessitates understanding these groups’ dynamics. Elderly chronic illness patients’ healthcare needs, functional limitations, and social support networks are also examined. Healthcare systems are complex, and these variables make the topic tough, requiring a thorough analysis.

Healthcare and socioeconomic issues arise from older chronic illness hospital readmissions in a growing aging society. Hospitalizations must be considered for cost and health risks. Therefore, this research issue is important and will provide essential insights to guide nursing education and practice. This research addresses literature gaps and investigates the causes of hospital readmissions for elderly patients transitioning to home care to optimize nursing interventions to reduce readmission rates and improve patient outcomes and healthcare system efficiency. An in-depth investigation of this problem, taking into account the organizations involved, is necessary to design evidence-based methods to improve home care for older people with chronic illnesses.

Local Problem – Nature and Severity of the Problem

The local problem of hospital readmission within 60 days after discharge to home care is a concern in our community and healthcare system. This issue hinders citizens’ health and costs local hospitals a significant financial burden. Understanding this problem’s scope is essential to finding solutions that improve patient care, lower healthcare costs, and optimize nursing practice.

The problem’s nature can be described as a loop of patients, especially older adults with chronic illnesses, being discharged from the hospital to get home care only to return soon after. This cycle shows a gap in the continuum of treatment, including the transition from hospital to home care. Readmissions often result from difficulties, medication errors, or inadequate post-discharge support. One of the critical aspects of the problem’s nature is its impact on the elderly population. Older adults have more chronic illnesses that require extensive care, and their physical and functional limitations may make them more susceptible to difficulties or setbacks following hospital discharge (Abdi et al., 2019). Our community’s growing older population, a trend seen worldwide due to demographic transitions, worsens the problem. This demographic transition directly affects an increasing section of our population, making hospital readmissions among this group more critical.

The financial costs to patients and healthcare organizations further underline the problem’s severity. According to Upadhyay et al. (2019), hospital readmissions cost patients, families, healthcare facilities, and the healthcare system. If a patient gets readmitted quickly, it shows that the initial care was ineffective and their health deteriorated. Readmissions increase healthcare expenses, burdening people financially and raising insurance premiums, reducing community access to care. Moreover, the severity of the problem is closely tied to patient satisfaction and overall healthcare outcomes. Readmissions can cause patient dissatisfaction as individuals often equate returning to the hospital with suboptimal care. This affects patients’ experiences and healthcare system trust. The patient may be readmitted several times and develop hospital-acquired infections and other health issues.

A local solution to improve the transition from hospital to home care, especially for older, chronically sick patients, is needed due to the problem’s nature and severity. This holistic solution should address drug management, patient education, caregiver assistance, and healthcare coordination. To ease the transition and reduce readmission rates, we must analyze our local healthcare organizations’ unique qualities and how to maximize them.

Generally, the local problem of hospital readmission within 60 days of homecare discharge is defined by a recurring cycle of patients returning. The expanding older population in our community, the financial consequences for individuals and healthcare institutions, and the influence on patient satisfaction and healthcare results worsen this situation. This problem must be addressed locally to improve patient care and healthcare quality and reduce the financial load on our healthcare system. A comprehensive approach that addresses our community and healthcare organizations’ specific qualities is needed to optimize nursing interventions and improve resident well-being.

Intended Improvement

The recommended homecare nursing interventions to reduce hospital readmission rates in older, chronically ill patients are designed to improve care procedures and patient outcomes. These multiple changes are essential for reducing hospital readmissions within 60 days of discharge. The following are critical areas for improvement.

Improved Patient Education and Empowerment

Nursing interventions aim to enable elderly chronic illness patients to maintain their health at home. This involves extensive education to help people understand their diseases, medication adherence, warning indicators, and proper care. Customized education and resources will help people manage their health independently, boosting self-efficacy and confidence in managing chronic conditions (Harvie, 2021). This, in turn, should lead to better self-care, fewer problems, and fewer hospital readmissions.

Medication Management and Adherence

Optimizing older medication management is crucial to the proposed strategies. Medication adherence rates should increase by simplifying prescription regimens, offering reminders, and ensuring patients understand the purpose and correct administration of their medications (Aremu et al., 2022). Reduced exacerbations and hospital readmissions can result from better medication adherence in chronic illness patients.

Care Coordination and Monitoring

Another critical dimension of the proposed interventions is the enhancement of care coordination and monitoring. To provide a coordinated and complete patient care strategy, nurses, physicians, and home health aides must streamline communication.Vital signs, symptom changes, and treatment plan compliance must be monitored often to identify concerns that could lead to hospital readmission (Coffey et al., 2022). Healthcare practitioners can prevent readmissions by strengthening care coordination and continuous monitoring.

Improved Health Literacy

The nursing interventions are designed to enhance health literacy among elderly patients with chronic illnesses. This development in health literacy should help people comprehend their illnesses, resources, and the significance of appropriate medical intervention. Patients who are better aware and competent in managing their health are less likely to delay seeking care, which can reduce problems and hospital readmission.

These intended improvements in care processes and patient outcomes should significantly improve homecare for older, chronically ill patients. The proposed interventions will likely reduce hospital readmissions within 60 days of discharge by addressing the factors that cause them, saving healthcare systems money, improving patient satisfaction, and, most importantly, improving health outcomes for this vulnerable demographic. These advances support healthcare goals like improving patient well-being, optimizing resources, and providing patient-centred home care.

Study Questions

The study intervention’s main improvement question is: “Can nursing interventions to improve patient education, medication management, care coordination, and health literacy significantly reduce hospital readmission rates within 60 days for elderly patients with chronic illnesses in-home care?”


Abdi, S., Spann, A., Borilovic, J., de Witte, L., & Hawley, M. (2019). Understanding the Care and Support Needs of Older people: a Scoping Review and Categorisation Using the WHO International Classification of functioning, Disability and Health Framework (ICF).
BMC Geriatrics,
19(1). https://doi.org/10.1186/s12877-019-1189-9

Aremu, T. O., Oluwole, O. E., Adeyinka, K. O., & Schommer, J. C. (2022). Medication Adherence and Compliance: Recipe for Improving Patient Outcomes.
10(5), 106. https://doi.org/10.3390/pharmacy10050106

Chen, H., Cates, T., Taylor, M., & Cates, C. (2020). Improving the US hospital reimbursement: how patient satisfaction in HCAHPS reflects lower readmission. International Journal of Health Care Quality Assurance, ahead-of-print(ahead-of-print). https://doi.org/10.1108/ijhcqa-03-2019-0066

Coffey, J. D., Christopherson, L. A., Williams, R. D., Gathje, S. R., Bell, S. J., Pahl, D. F., Manka, L., Blegen, R. N., Maniaci, M. J., Ommen, S. R., & Haddad, T. C. (2022). Development and implementation of a nurse-based remote patient monitoring program for ambulatory disease management.
Frontiers in Digital Health,
4. https://doi.org/10.3389/fdgth.2022.1052408

Harvie, D. S. (2021). Immersive Education for Chronic Condition Self-Management.
Frontiers in Virtual Reality,
2. https://doi.org/10.3389/frvir.2021.657761

Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission Rates and Their Impact on Hospital Financial Performance: A Study of Washington Hospitals.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing,
56(56), 004695801986038. https://doi.org/10.1177/0046958019860386


The Process of Program Planning

Implementing Change through Planned Interventions

Diana Aranda

Denver College of Nursing


Instructor’s Name: Sharon Bator


The Process of Program Planning

Implementing Change through Planned Interventions


The chosen topic for the scholarly paper is “Hospital readmission within 60 days after discharge to homecare,”. This topic is a significant concern in nursing education and healthcare practice. Hospital readmissions affect patient well-being and healthcare expenditures, especially for senior chronic illness patients transferring to home care (Chen et al., 2020). We will discuss the research question, write a detailed summary statement, and choose a journal for manuscript submission.  

The research question is: “What factors contribute to hospital readmission within 60 days of discharging from the hospital to homecare services, and how can nursing interventions be optimized to reduce readmission rates among elderly patients with chronic illnesses in the homecare setting?” This well-structured research question addresses nursing education and patient care concerns. According to Lo et al. (2021), hospital readmission within a short time after discharge shows that the patient’s health may have deteriorated, the initial discharge was early, or homecare may not have been enough to sustain health. This research question investigates hospital readmissions and recommends nursing interventions to reduce readmissions in vulnerable elderly patients with chronic illnesses getting home care.

Summary Statement

This research paper aims to investigate hospital readmission within 60 days after discharge and transition to homecare services. Hospital readmissions are essential to healthcare quality, patient outcomes, and system efficiency. This research focuses on older chronic illness patients with complex healthcare demands requiring ongoing attention. Hospital readmissions in this demographic can increase healthcare expenditures, patient dissatisfaction, and bad outcomes. This research seeks to explore the causes of hospital readmissions in this scenario. It investigates what causes these readmissions and, more importantly, how nursing interventions can be adjusted to reduce homecare readmission rates for this patient population.

The potential impact of this research is substantial. Addressing hospital readmission improves patient care and advances nurse education and practice. The findings of this study can help nursing educators, practitioners, and policymakers establish evidence-based practices and interventions. Health systems can save money, enhance patient outcomes, and improve care with these strategies. This article aims to help healthcare professionals, educators, and administrators enhance home care for older individuals with chronic conditions. This research could improve nursing education and practice, helping patients and the healthcare system.

Journal Selection

The ideal journal for submitting the hypothetical manuscript is “The Journal of Nursing Research.” This nursing journal is known for publishing high-quality research. It is ideal for sharing nursing intervention findings, notably on patient readmissions. The journal’s reputation and focus match this research’s goals. The author’s “The Journal of Nursing Research” rules will be strictly followed to guarantee that the paper meets the highest professional standards. These recommendations help communicate study findings and meet nursing research community expectations. Following these principles will assist in maintaining nursing research rigor and professionalism, even though the paper will not be published.


The issue of hospital readmission within 60 days of discharge to home care is a crucial concern in nursing education and healthcare practice. The well-structured study topic examines hospital readmission factors and nurse intervention optimization to reduce readmission rates, especially in older home care patients with chronic diseases. The summary statement describes the paper’s goal and potential influence on nursing education and practice. The selected journal, “The Journal of Nursing Research,” matches the research’s topic and will guide paper submission. This research could improve patient care, healthcare quality, and nursing knowledge.


Chen, H., Cates, T., Taylor, M., & Cates, C. (2020). Improving the US hospital reimbursement: how patient satisfaction in HCAHPS reflects lower readmission.
International Journal of Health Care Quality Assurance,
ahead-of-print(ahead-of-print). https://doi.org/10.1108/ijhcqa-03-2019-0066

Lo, Y.-T., Chang, C.-M., Chen, M.-H., Hu, F.-W., & Lu, F.-H. (2021). Factors associated with early 14-day unplanned hospital readmission: a matched case–control study.
BMC Health Services Research,
21(1). https://doi.org/10.1186/s12913-021-06902-6


Process of Program Planning

Student’s name

Institutional Affiliation

Course name

Professor’s name

Due date

Process of Program Planning

Workplace for change

The workplace where change will be instituted is a medium-sized community hospital. This hospital provides emergency care, surgical procedures, and inpatient care services. It has several specialized units, such as the maternity ward, surgical department, and critical care unit. The change will focus on the medical-surgical unit level, where change will be instituted. The hospital is facing persistent high readmission rate in the medical-surgical unit. Significant number of patients are returning to the hospital shortly after discharge. It places additional strain on healthcare resources and suggests underlying issues in quality of care, post-discharge support, or patient education. Addressing the high readmission rate is imperative to improve patient outcomes, reduce healthcare costs, and ensure patients receive the comprehensive care and guidance needed to recover successfully (Warchol et al., 2019).

Team needed to change.

The team would ideally comprise a nurse Manager to provide insights into daily operations, staffing, and nursing protocols within the unit. Clinical Nurse Specialists offer clinical expertise in patient care and identify areas for improvement. Case manager to assess the discharge planning process and its effectiveness. Data Analyst to analyze readmission data and identify patterns and trends. Patient Educator to evaluate patient education programs and their impact. Quality improvement coordinator to facilitate process improvement initiatives. Physician representative to provide medical input and perspectives on patient care. IT Specialist to assess the technological tools and systems supporting patient care and discharge processes.

The rationale for selecting the individuals is to create a well-rounded team to address all aspects of the change initiative. Nurse Manager and Clinical Nurse Specialists possess frontline experience and clinical insights, while the Case Manager understands discharge process intricacies. Data Analysts bring data-driven insights. Patient Educators offer perspectives on patient understanding and compliance and Quality Improvement Coordinators facilitate process enhancements. Physician Representatives provide essential medical input, and IT Specialists assess technological support systems (Taberna, 2020).

The team members fulfill team roles within the change initiative. The nurse manager and clinical nurse specialists can be seen as front-line leaders who understand the impacts of changes on healthcare delivery processes. The case manager and quality improvement coordinator are champions for the change, as they are dedicated to improving the discharge process and overall quality of care. Data analyst provides clinical or technical expert knowledge in analyzing readmission data. Patient Educator and IT Specialist contribute their expertise to different initiative aspects and offer valuable insights and support.

Interdisciplinary Teams Impact

Interdisciplinary change teams are impactful than one discipline. Patient care is highly interdisciplinary in healthcare settings, and many issues require a multifaceted approach. Interdisciplinary team expertise ensures comprehensive understanding of the issue and holistic approach to finding solutions. Secondly, it offers Diverse Perspectives that can result in innovative and well-rounded. Thirdly, interdisciplinary teams can better address these challenges by pooling their collective skills and experiences. Interdisciplinary teams also encourage better communication, improved care coordination, reduced errors, and a more patient-centered approach (Bendowska & Baum, 2023).


Bendowska, A., & Baum, E. (2023). The Significance of Cooperation in Interdisciplinary Health Care Teams as Perceived by Polish Medical Students.
International Journal of Environmental Research and Public Health,
20(2), 954. https://doi.org/10.3390/ijerph20020954

Taberna, M. (2020). The multidisciplinary team (MDT) approach and quality of care.
Frontiers in Oncology,
10(85). https://doi.org/10.3389/fonc.2020.00085

Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W.-W. (2019). Strategies to reduce hospital readmission rates in a non-Medicaid-expansion state.
Perspectives in Health Information Management,
16(Summer). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669363/


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