NU507 Unit 10 delivery redesign proposal example

One Population, One Model, One Owned Handoff: A Delivery Redesign Proposal for Older Adults With Repeat Admissions on a Composite Medical Section

[Student Name]

Purdue University Global

NU507: Promoting Optimal Models and Systems for Health Care Delivery

Unit 10 Assignment

[Instructor Name]

[Date]

The system, section, costs and targets are composite and bracketed; the models and evidence cited are published. Program and payment details are recorded as of the date of writing.

Executive Summary

Request: approve a six-month pilot of primary nursing for a defined population on one twelve-bed section of the medical unit, with a mandatory warm handoff to the patient's clinic registered nurse care manager at discharge.

Population: patients aged 65 or over with at least two of the listed long-term conditions and a hospital stay within the previous year; about [260] patients and [410] admissions a year on the unit, with a 30-day readmission rate of [24] percent.

Cost: about $[384,000] a year in added registered nurse cost on the section, net of licensed practical nurse redeployment into existing vacancies.

Targets, stated as targets rather than promises: nurse continuity index for qualifying patients from [0.3] to at least [0.6]; a recorded phone handoff to the care manager for [four in five] qualifying patients before they go home; first clinic contact within seven days for at least [70] percent; no rise in falls with injury, pressure injuries or registered nurse turnover. Readmission is tracked and reported but, given the pilot's size, is not the pass or fail criterion for the first six months.

The Population

The profile defined the population in reproducible terms and found four needs any delivery model must meet for these patients: someone who knows them through the stay, a medication plan that survives discharge, teaching that reaches the family member doing the work, and a route to follow-up care. Record review of [30] readmissions placed most breakdowns in the days before anyone from the clinic made contact, often within 72 hours of leaving, and often involving a medication change that did not reach the person managing pills at home.

The Current Model and Its Premise

Team nursing on the unit assumes that written plans and shift reports can stand in for one nurse knowing the patient. For this population, the premise fails where it matters: a five-day stay meets several team leaders, teaching often happens on the discharge morning, and nobody is responsible for the days after the patient leaves and before the clinic hears of it.

The Evidence and Its Certainty

The evidence for unit-level care delivery models is weak. The Cochrane review of staffing models rated what little it found on primary nursing as very low in certainty, and no readmission outcomes (Butler et al., 2019). The strongest evidence for reducing readmissions in this population comes from interventions that carry responsibility across discharge: advanced practice nurse transitional care reduced readmissions of older adults by 24 weeks from 37.1 to 20.3 percent (Naylor et al., 1999), and a care transitions coaching intervention reduced 30-day rehospitalization from 11.9 to 8.3 percent (Coleman et al., 2006). The proposal is scaled to match: it combines a plausible unit-level mechanism with the better-supported element, the owned handoff, and evaluates both.

The Proposed Model, Justified Need by Need

Continuity. A primary nurse is assigned at admission and holds each qualifying patient's plan until discharge (Manthey, 2002), with a consistent associate nurse on the primary nurse's days off.

Medication management. The primary nurse reconciles medications across the stay, not only at discharge, and teaches changes as they happen.

Caregiver support. The primary nurse identifies the person who manages care at home and schedules teaching when that person can be present, by phone if necessary.

Access. Before the patient leaves, the primary nurse phones the clinic's registered nurse care manager, who then reaches the patient by phone inside two days and can bring the first visit forward.

The clinic side is framed by the Chronic Care Model, in which an informed, activated patient and a prepared, proactive practice team, supported by care management and clinical information systems, produce better chronic illness care (Bodenheimer et al., 2002). The care managers already exist in the system's primary care clinics; the proposal gives them a reliable signal from the hospital.

The Transition and Its Costs

The transition plan adds 6.3 registered nurse FTEs to the section and redeploys 4.2 licensed practical nurse FTEs into vacancies on the unit's other sections, at a net cost of about $[384,000] a year. It runs in four phases over six months: preparation with baselines and role orientation, an eight-week pilot, evaluation and a decision. No licensed practical nurse loses employment.

Indicators and the Decision Rule

The committee approved nine indicators before the model decision, including the internal 30-day readmission rate for the population, NDNQI falls with injury and pressure injuries, nursing hours and skill mix, the HCAHPS nurse communication composite, a nurse continuity index and registered nurse turnover. The decision rule, set in advance, extends the pilot if continuity and handoff measures reach their targets without harm, adjusts it if mechanism measures fall short, and stops it if harm or staffing measures fail.

Alternatives Considered

Whole-unit primary nursing. Rejected on staffing. Converting all 36 beds would add about 19 registered nurse FTEs in a labor market where the unit's vacancy rate was [22] percent three years ago, and it would apply the model to patients whose needs do not require it.

Hospital at home. Deferred, with a date. The trial evidence is favorable: in a randomized trial, patients treated at home had lower costs and fewer readmissions (Levine et al., 2020). But Medicare's program requires an in-person emergency response within 30 minutes (Centers for Medicare and Medicaid Services, 2020), which excludes the [38] percent of this population living more than 30 miles from the clinic and many within that distance on rural roads, and its authorization has rested on short extensions. The proposal therefore defers hospital at home in two ways: for patients beyond a [20]-mile radius, because the response rule cannot be met, and for those within it, until [date], when the program's authorization and the system's paramedic coverage can be reassessed.

Continue team nursing with the handoff alone. This is the fallback if the pilot fails on staffing: the warm handoff can operate under team nursing, and the proposal recommends keeping it whatever the model decision.

Financial Context

The system's accountable care organization participates in the Medicare Shared Savings Program, and reducing avoidable admissions for patients with multiple chronic conditions is part of how the ACO is assessed in the performance years to date. That creates a financial reason for the system to invest in the handoff, but the proposal does not claim savings from the pilot, which is too small to show them within six months.

Risks

Staffing may not hold at the proposed level; twelve-hour schedules will interrupt continuity; care managers may not be reachable at discharge times; and the model's evidence is weak. Each risk has a response in the transition plan's register, and the decision rule allows the pilot to stop.

Closing

The proposal returns to the population it began with: older adults who come back to the unit because the plan made for them did not survive the trip home. It does not ask the system to adopt a new model everywhere. It asks for one section, one owned handoff and an honest test.

References

Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. JAMA, 288(14), 1775-1779. https://doi.org/10.1001/jama.288.14.1775

Butler, M., Schultz, T. J., Halligan, P., Sheridan, A., Kinsman, L., Rotter, T., Beaumier, J., Kelly, R. G., & Drennan, J. (2019). Hospital nurse-staffing models and patient- and staff-related outcomes. Cochrane Database of Systematic Reviews, 2019(4), CD007019. https://doi.org/10.1002/14651858.CD007019.pub3

Centers for Medicare and Medicaid Services. (2020). Acute Hospital Care at Home (QSO-21-06-Hospitals) [Memorandum to state survey agency directors].

Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822

Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-level care at home for acutely ill adults: A randomized controlled trial. Annals of Internal Medicine, 172(2), 77-85. https://doi.org/10.7326/M19-0600

Manthey, M. (2002). The practice of primary nursing (2nd ed.). Creative Health Care Management.

Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613-620. https://doi.org/10.1001/jama.281.7.613