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Phase 1 and  2 attached PHASE 1 2 PHASE 1- PLANNING Introduction to the problem Transitional nursing is Care provided to patients as they transit from one place to another. Transition can be within the hospital setting, between care settings, within health states, and between providers (Warchol et al., 2019). One of the transitions is discharge from the hospital to home care. Patients are discharged from the hospital before they are completely cured but must be well off to be able to recover at home. The patients are sent home with treatment packages and sometimes may require frequent clinical visits by the nursing for care. The care plan during the transition from hospital to home care includes the treatment goals, the health status of the patient, treatment preferences and family as well as patient education. Coordination is crucial in this care. In some cases, these discharge packages are not well elaborated. Miscommunication and discontinued care may result in adverse effects on the patient. For example, the patient may experience delayed care, unnecessary clinical visits, and stress to the patient or family, and poor health outcomes. Problem statement The transition of the hospital to home care is done to enable the client to recover at home. Healthcare professionals discharge clients with strict instructions for the client to continue with care and recover fast. Due to poor communication and nursing care at home, many patients face readmission. Readmission is defined as the return to hospitalization within 30 days of discharge from the same condition. Readmission is among the costliest cases in the hospital setting to manage. Hospitals incur huge costs in managing readmission. The federal government is also affected. The US spends $17.4 billion on readmission costs. Hospitals readmit 20\% of patients enrolled in Medicare within 30 days upon discharge and 34\% of the clients within 90 days of discharge. Unwanted and unnecessary health care costs amount to $765 billion yearly with preventable admission accounting for $17 billion for Medicare (Warchol et al., 2020). Causes of readmission are varied. Poor resolution of the original problem of the patient is a major cause of readmission. The healthcare provided by professionals just relieves the pain and not the actual problem. In such a case it is likely to reoccur. Discharge of patients too early may be a cause of readmission. The patient is discharged before being stable enough to recover from home. In other cases, inadequate care after discharge may make the condition worse. The nurse has a critical role to play in the provision of care at such transition (Rezapour-Nasrabad, 2018). Significance of the study The significance of this study is to inform nurses of the gaps within the hospital-home transition care and informing the necessary course of action to prevent readmission of clients. The study will identify the major problems nursing practitioners face in transition care. Transition care costs health facilities billions of dollars which could be avoided with proper intervention. Proper communication and collaboration between health care providers post and Pre discharge can provide coordinated care for better health outcomes. Adequate care post disgrace will reduce the rate of readmission. The study will be significant to clinics and other healthcare centers. The billions of dollars that government spends on readmission could be channeled to other treatment avenues. Nurses and doctors can work in harmony and coordinate care during the transition. Through education of patients, families, effective care is possible and can help to reduce readmission. Purpose of the study The purpose of this study is to investigate methods nurses use to reduce the readmission of patients after discharge. Most patients undergo a state of depression together with their kin because of the reoccurrence of diseases that could be avoided before discharge. Going back to the hospital makes it costly for instance to people who are not enrolled in health insurance cover (Upadhyay et al., 2019). In the US, the costs families incur during readmission dent their economic stability, resulting in them using coping strategies to mitigate the financial challenges. The study will assess the major methods that can be used by clinicians to prevent readmission. Treatment of the main condition rather than the symptoms as well as proper communication between health professionals during discharge is essential in promoting patient recovery. In addition, nurses can take an active role in improving care for patients in a transition phase. Making the necessary interventions can reduce the rates of readmission in the hospital setting. The hospital should be a temporary place for the treatment of patients before discharge within the shortest time possible. Long hospital stay is associated with poor health outcomes and increased costs. Research Questions The study wishes to find key issues surrounding nursing care during the transition. The nurse has a critical role in the management of students to minimize readmission rates. Some of these research questions to be addressed include; 1. What strategies can hospitals put in place to prevent readmission of patients? 2. What is the role of nurses in the transition care of patients? 3. What is the role of hospital management in ensuring they reduce readmission costs? 4. What is the purpose of communication between professionals before the discharge of patients? Masters essentials aligned to the study Nursing care is an essential component in patient management. Nursing skills acquired in training can be well utilized to provide comprehensive and timely care to all patients. During transition care, nurses efforts ought to be recognized and acquired to assist patients to recover well at home or any other transitory place or setting. Research gaps still exist that nurses can explore and recommend necessary actions for continuous implementation in patient management. With the proper application of nursing theories, nurses can develop philosophies that can go a long way in changing patient care in hospitals and beyond. Developing a research problem statement should be the pursuit of any nurse who wishes to contribute immensely in the field of medicine. In conclusion, nurses and healthcare are synonymous. To achieve adequate patient management, the efforts and contributions of nurses should be the core element in the development of treatment measures for clients. Transition care, for instance, requires the input of all healthcare professionals and adequate planning as well as communication and elaboration of the plans to achieve the goals. Research can contribute immensely to the development of adequate care plans for patients and their families in transition care (De Regge et al., 2017). Nursing care not only seeks to achieve physical wellbeing but also the emotional well-being of the client and the family in times of distress. References De Regge, M., De Pourcq, K., Meijboom, B., Trybou, J., Mortier, E., & Eeckloo, K. (2017). The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions. BMC Health Services Research, 17(1), 1-24. Rezapour-Nasrabad, R. (2018). Transitional care model: managing the experience of hospital at home. Electronic Journal of General Medicine, 15(5). 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, 0046958019860386. 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). 1 9 Phase 2- Design Phase 2- Design Brief literature review For too many patients, the healthcare door is one that they consider to be a revolving one. Approximately 20\% regarding the Medicare patients usually leave the healthcare centers only for them to be readmitted within a months time. The failure to come up with the standard discharge processes, efficient preparation of patients and the family caregivers for discharge, effective education of patients in regard to medications and communicate appropriately with the identified post discharge providers is all associated with causing readmissions (Chen et al., 2021). Through effective coordination as well as communication, planning and education, nurses as well as the nurse case administrators can play a key role in the reduction of readmissions. Beginning at the admission phase, there is the possibility of the mitigation of readmission risks at the various points in the cases of pre discharge as well as post discharge periods via effective determination of the readiness for discharge by the patients as well as the compilation of an extensive as well as accurate form of discharge summary, coordination of care with numerous settings as well as providers and much more. Nursing Interventions during the Process of Discharge Most of the studies usually connect readmissions with the lack of effective and fast follow up by the identified primary care type of providers as well as other kinds of healthcare experts. Patients ought to possess an effective follow up appointment that is scheduled within 48 hours to am average of7 days after they have been discharged. There are numerous strategies in this case which can be used which are the development of scheduling kinds of agreements with the local clinics like the system affiliated ambulatory care kinds of clinics. There is also the creation of processes for the assignment of patients to an identified PCP if they lack one. It is also vital to facilitate effective education of patients as well as the home caregivers on the significance associated with timely as well as effective follow up (Lee et al., 2021). Post discharge nursing related interventions The identified period immediately after any kind of patient discharge is one that is considered to be a vulnerable time for the patients one whereby rapid alterations can take place. Having a follow up with the identified patients as well as the home types of caregivers soon after the identified discharge can minimize confusion as well as effectively reinforce the follow up kind of plans. The most common topics to be discussed in the first post discharge phone call entails the medications as well as pending services and more (Wong et al., 2021). Discharge to a setting other than home When a given patient is considered to be discharged to a setting that is other than the home, nurses as well as the NCMs can effectively play a key role in the prevention of the transfer back to the identified hospital. Interventions to minimize the acute transfers is considered to be a quality improvement kind of program which is associated with the provision of an evidence based kind of guide and the necessary tools formulated to minimize transfers from the identified long term care as well as assisted living settings to the acute care kinds of hospitals. This is essential in enhancing patient safety as well as satisfaction and in the reduction of readmissions via early identification as well as evaluation of the key changes in the condition of the patients (Maki et al., 2021). Halting the readmission cycle Hospital readmissions are considered to be expensive to the patients as well as the healthcare facilities. Nurses as well as the NCMs are considered to be natural communicators as well as educators which puts them in a perfect position to assist in the prevention of readmissions at various points. Being familiar with as well as utilizing easily accessible, evidence based tools can assist nurses as well as the NCMs in the management of patient transitions optimally and even consistently (McHugh et al., 2021). Methodology and design of the study Intervention Mapping is considered as being a systematic as well as an iterative six phases process which assists in the development of an intervention kind of system on the basis of the theoretical as well as empirical and even practical information. IM was initially utilized appropriately in the identified health promotion kind of domain to come up with programs for the issue of smoking cessation as well as stroke prevention, HIV prevention and leg ulcer management. There is the use of PRECEDE PROCEED MODEL to effectively analyze as well as illustrate the identified scale along with causes and even impacts regarding Health issues and in the identification of the target population. Procedure & participants A literature kind of search on the identified frequency as well as impacts regarding ineffective hospital discharge issue will be performed. There will be the performance of a large kind of qualitative study on the identified patient handovers between the identified acute care healthcare centers as well as the primary care in the US. This will be vital in the identification of the behavioral as well as the environmental Level determinants impacting ineffective healthcare centers discharge. The study to be performed will adhere to RATS which stands for relevance as well as Appropriateness, Transparency and Soundness guidelines for the qualitative types of studies. Data analysis as well as analysis will comprise of multi-method kind of qualitative study inclusive of the individual as well as the focus group kinds of interviews, process maps and the artefacts Analysis. Intervention Results, performance Goals & change Goals There was also the identification of the desired results regarding the intervention as well as formulated particular performance objectives for the identified target population like writing of a complete as well as accurate and even timely kind of discharge letter by the identified hospital physician. This led to a step by step kind of checklist regarding what needs to be achieved so as to attain the most effective results. It is vital to facilitate the identification of the necessary steps needed to be tweaked so as to impact the performance goals and eventually the intervention results. There was the identification of the most vital kind of determinant such as the lack of knowledge as well as comprehensive understanding between the healthcare center as well as the primary care types of providers which are required to be altered as well as combined these with the performance goals to design the alteration goals. Sampling methodology Stratified sampling In this method, the identified population is usually first divided into key subgroups or even strata who are all involved in sharing of the same features. It is usually utilized when the researchers may reasonably anticipate the identified measurements regarding the interest to vary between the distinct kinds of subgroups and there is the need to make sure there is representation from all the identified subgroups. In this kind of sampling Methodology, the identified study sample is usually obtained via taking equal and fair sample sizes from each of the given stratum. In the stratified kind of sampling, it is also considered to be vital to select non-equal sample sizes from each of the identified stratum. This is vital in ensuring there is the achievement of a highly realistic as well as accurate estimation regarding the health outcomes regarding nurses across the region while for simple random kind of sampling, there would be the over representation of the nurses from the identified healthcare centers. It is vital to understand that the fact that the given sample was effectively stratified ought to be put into consideration at the identified analysis stage. This kind of sampling Methodology helps in the improvement of accuracy as well as representativeness regarding the outcomes by the reduction of the sampling bias (Valliant et al., 2018). Necessary tools The necessary tools are audio recorders as well as form plus online kind of questionnaire. The audio recorder is utilized for the key aim of recording sound on the discs as well as tapes and films. The audio kind of information is considered to be highly suitable since it can effectively meet the key needs regarding a wide range of individuals along with offering alternatives to the printing of data gathering tools (Narasimharao et al., 2017). Form plus is associated with letting an individual to effectively create strong forms to assist in the collection of the information which is needed. It is vital in the creation of online forms for getting actionable trends as well as measurable kinds of responses. Any algorithms or flow maps created References Chen, J., Wijesundara, J. G., Patterson, A., Cutrona, S. L., Aiello, S., McManus, D. D., ... & Houston, T. K. (2021). Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses’ and patients’ perspectives. BMC Health Services Research, 21(1), 1-15. Maki, S., Nagai, K., Ando, S., & Tamakoshi, K. (2021). Structure and predictors of in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia in Japan: A cross-sectional study. PLoS one, 16(4), e0250771. McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. The Lancet, 397(10288), 1905-1913. Oh, E. G., Lee, H. J., Yang, Y. L., & Kim, Y. M. (2021). Effectiveness of discharge education with the teach-back method on 30-day readmission: a systematic review. Journal of patient safety, 17(4), 305-310. Valliant, R., Dever, J. A., & Kreuter, F. (2018). Practical tools for designing and weighting survey samples. Wong, C. H., Cheung, W. K., Zhong, C. C., Yeoh, E. K., Hung, C. T., Yip, B. H., ... & Chung, V. C. (2021). Effectiveness of nurse-led peri-discharge interventions for reducing 30-day hospital readmissions: Network meta-analysis. International Journal of Nursing Studies, 103904. Phase 3-Implementation (Due by WEEK 9) Phase 3 of the research project is the implementation phase. The implementation phase will be written state as we will not be implementing the actual project. This phase focuses on providing steps by steps instructions on how the program will be implemented, a table describing the time frame of the project, if any budget needs to be considering, and any resources or statistically tools required. The length of this paper should be around 5-6 pages. Outstanding 10 points Very Good 8 points Good 6 Points Unacceptable 4 points Integration of Knowledge 12.5\% The paper demonstrates that the author understands and has applied concepts learned in the course. Concepts are integrated into the writer’s own insights. The writer provides concluding remarks that show analysis and synthesis of ideas The paper demonstrates that the author, mostly, understands and has applied concepts learned in the course. Some conclusions, however, are not supported in the body of the paper The paper demonstrates that the author, to a certain extent, understands and has applied concepts learned in the course The paper does not demonstrate that the author has understood, and applied concepts learned in the course. Topic Focus 12.5\% The topic is focused narrowly enough for the scope of this assignment. A thesis statement provides direction for the paper, either by a statement of a position or hypothesis The topic is focused but lacks direction. The paper is about a specific topic, but the writer has not established a position. The topic is too broad for the scope of this assignment. The topic is not clearly defined Depth of Discussion 12.5 \% In-depth discussion and elaboration in all sections of the paper. In-depth discussion and elaboration in most sections of the paper. The writer has omitted content. Quotations from others outweigh the writer’s own ideas excessively. Cursory discussion in all the sections of the paper or brief discussion in only a few sections Cohesiveness 12.5\% Ties together information from all sources. Paper flows from one issue to the next with no headings. Author’s writing demonstrates an understanding of the relationship among material obtained from all sources Mostly, it ties together information from all sources. Paper flows with only some disjointedness. The author’s writing demonstrates an understanding of the relationship among material obtained from all sources. Sometimes ties together information from all sources. Paper does not flow. Disjointedness is apparent. The author’s writing does not demonstrate an understanding of the relationship among material obtained from all sources. It does not tie together information. Paper does not flow and appears to be created from disparate issues. Headings are necessary to link concepts. Writing does not demonstrate understanding any relationship Spelling and Grammar 12.5\% Minimal spelling and/or grammar mistakes Some spelling and or grammar mistakes. Noticeable spelling and grammar mistakes. An unacceptable number of spelling and/or grammar mistakes Sources 12.5\% Over 5 current sources, of which at least 3 are peer-review journal articles or scholarly books. Sources include both general background sources and specialized sources. Special-interest sources and popular literature and acknowledged as such if they are cited. All web sites utilized are authoritative. 5 current sources, of which at least 2 are peer-review journal articles or scholarly books. All web sites utilized are authoritative. Fewer than 5 current sources or fewer than 2 of 5 are peer- reviewed journal articles or scholarly books. All web sites utilized are credible. Fewer than 5 current sources or fewer than 2 of 5 are peer- reviewed journal articles or scholarly books. Not all web sites utilized are credible, and/or sources are not current. Citations 12.5\% Cites all data obtained from other sources. APA citation style is used in both text and bibliography Cites most data obtained from other sources. APA citation style is used in both text and bibliography. Cites some data obtained from other sources. Citation style is inconsistent or incorrect. Does not cite sources. · Score 6.48 / 10 · Integration of Knowledge 25\% of total result 1.5 Oustanding The paper demonstrates that the author understands and has applied concepts learned in the course. Concepts are integrated into the writer’s own insights. The writer provides concluding remarks that show analysis and synthesis of ideas. 2.5 Very Good The paper demonstrates that the author, mostly, understands and has applied concepts learned in the course. Some conclusions, however, are not supported in the body of the paper. 2 Good The paper demonstrates that the author, to a certain extent, understands and has applied concepts learned in the course. 1.5 Unacceptable The paper does not demonstrate that the author has understood, and applied concepts learned in the course. 1 Criterion Feedback Please read the detailed feedback within this paper- several areas of concern that need to be corrected prior to final submission · Topic Focus 25\% of total result 1.5 Oustanding Topic Focus 12.5\% The topic is focused narrowly enough for the scope of this assignment. A thesis statement provides direction for the paper, either by a statement of a position or hypothesis 2.5 Very Good The topic is focused but lacks direction. The paper is about a specific topic, but the writer has not established a position. 2 Good The topic is too broad for the scope of this assignment. 1.5 Unacceptable The topic is not clearly defined. 1 Criterion Feedback Topic needs to be more focused and developed - not clearly articulated within the paper See feedback · Depth of Discussion 13\% of total result 0.78 Oustanding In-depth discussion and elaboration in all sections of the paper. 1.3 Very Good In-depth discussion and elaboration in most sections of the paper. 1.04 Good The writer has omitted content. Quotations from others outweigh the writer’s own ideas excessively. 0.78 Unacceptable Cursory discussion in all the sections of the paper or brief discussion in only a few sections 0.52 Criterion Feedback Multiple areas of development needed- missing key information on the discussion See feedback Sample size, inclusion, exclusion criteria, flow charts or graphs, a place where the study was to take place, ethical considerations etc.. should be developed. · Cohesiveness 13\% of total result 0.78 Oustanding Ties together information from all sources. Paper flows from one issue to the next with no headings. Author’s writing demonstrates an understanding of the relationship among material obtained from all sources Mostly, it ties together information from all sources. 1.3 Very Good Mostly, it ties together information from all sources. Paper flows with only some disjointedness. The author’s writing demonstrates an understanding of the relationship among material obtained from all sources. 1.04 Good Sometimes ties together information from all sources. Paper does not flow. Disjointedness is apparent. The author’s writing does not demonstrate an understanding of the relationship among material obtained from all sources. 0.78 Unacceptable It does not tie together information. Paper does not flow and appears to be created from disparate issues. Headings are necessary to link concepts. Writing does not demonstrate understanding any relationship 0.52 Criterion Feedback There are areas that do not tie in to the overall these or topic- please visit the writing lab- multiple error found within the paper · Spelling and Grammar 12\% of total result 0.72 Oustanding Minimal spelling and/or grammar mistakes 1.2 Very Good Some spelling and or grammar mistakes. 0.96 Good Noticeable spelling and grammar mistakes. 0.72 Unacceptable An unacceptable number of spelling and/or grammar mistakes. 0.48 Criterion Feedback see feedback · Sources 6\% of total result 0.6 Oustanding Over 5 current sources, of which at least 3 are peer-review journal articles or scholarly books. Sources include both general background sources and specialized sources. Special-interest sources and popular literature and acknowledged as such if they are cited. All web sites utilized are authoritative. 0.6 Very Good 5 current sources, of which at least 2 are peer-review journal articles or scholarly books. All web sites utilized are authoritative. 0.48 Good Fewer than 5 current sources or fewer than 2 of 5 are peer-reviewed journal articles or scholarly books. All web sites utilized are credible. 0.36 Unacceptable Fewer than 5 current sources or fewer than 2 of 5 are peer-reviewed journal articles or scholarly books. Not all web sites utilized are credible, and/or sources are not current. 0.24 · Citations 6\% of total result 0.6 Oustanding Cites all data obtained from other sources. APA citation style is used in both text and bibliography . 0.6 Very Good Cites most data obtained from other sources. APA citation style is used in both text and bibliography. 0.48 Good Cites some data obtained from other sources. 0.36 Unacceptable The citation style is inconsistent or incorrect. It does not cite sources.