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Similarity Less than 10 \% Instructions attached PHASE 1 2 PHASE 1- PLANNING Alina Rivero Parets Florida National University Nursing Research and Evidence Based Dr. Nora Hernandez-Pupo September 21,2021 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). Research Paper Rubric Phase 2-Design (Due by WEEK 6) Students will continue their research topic, in this paper students will perform a brief literature review on the topic (Will need at least 5 support articles) and provide the desired methodology for the project. Paper will be approximately 5-6 pages.  1. Brief literature review 2. Methodology and design of the study (Be detailed ) 3. Sampling methodology 4. Necessary tools 5. Any algorithms or flow maps created. This will be considered a Library Assignment as you will need to visit the library to obtain information. 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. The citation style is inconsistent or incorrect. It does not cite sources.