There is increasing pressure on the hospitals to ensure minimal hospital readmission. The US has even made a regulatory framework that penalizes and lowers Medicare benefits for hospitals with excess admission rates. Because of the high costs associated with readmission, and in the interest of patient's well-being, the various framework has been suggested to help the hospitals reduce and evaluate readmission, key among them being: patient-centered model, transition care model (TCM) and care coordination model. The model enjoys the support of some analysis for being a self-sustainable way to promote patient well-being. This paper briefly examines these models and then evaluates how they have Solutions Center Project applies them.
Description of the Evaluation Model
Transition care model
This strategy entails undertaking patients' transition needs (between the time of discharge till the patient fully recuperates) and then providing support that is tailored to the patient's needs. Among possible transition measures include giving the patient health care support, making available a transition care coordinator and offering follow-up medications (Kripalani, S., Theobald, Anctil, & Vasilevskis, 2014). The main areas of focus at the assessment stage include timeliness for follow-up, evaluation of medication needs, intervention against risk factors and functional status limitations. The hospital will grant attention according to the needs of the patient so that ones with greater needs get increased attention than those with lesser medication needs.
Patient-Centered Model
This model places emphasis in engaging the patient in their medical and nursing care, thereby empowering them to monitor and follow the discharge instructions (Fontanarosa & McNutt, 2013). The model also seeks to equip the patient to monitor their progress after leaving the acute care setting.Unlike the TCM where the medical practitioners are more actively engaged, in this model the patients are the most powerful actors and the health service providers merely do the supportive role. Patient education is at the centre-stage of this model. The model goes along with the provision of transition coaches, planning for possible barriers (especially the non-medical ones) as well as post-discharge follow-up communications.
Care-coordination model
Care coordination model seeks to put in place coordinated care programs, by bringing on board various stakeholders (organizations, health care institutions, patients, and professionals) and coordinating them to offer high-quality transitions and referrals (Morando et al., 2016). It puts emphasis on setting agreements and relationships that foster patient care and realization of shared expectations, through the timely and efficient flow of communication as well as actions.
Descriptions of the Model
The Solutions Center Project has attempted to incorporate all the three approaches above, even though not with equal emphasis. A possible explanation for adopting multiple designs to reducing hospital admission may be to benefit from various advantages that come with each approach. Even then, the plan is majorly based on stakeholder collaboration. The table below how each of the three evaluation models is reflected in the Solutions Center Project.
Transition care model Patient-Centered Model Care-coordination model
The project provides for risk assessment
Patients at high risk are given specialized support during transition
The project provides for making follow-up communications with the patients and their families to promote favorable health outcome Patients are provided with clinical outreach, as a means of supporting them.
Patients at high risk are given specialized support
The patients together with their families are made part of transition arrangement, with the aim of empowering them. The project provides for stakeholder collaboration in , risk assessment clinical care and outreach. Among key stakeholders involved include the patients, the families of the patient, health care professionals and the employees of the hospital.
Financial adjustments are made in service provision, taking into account the need for economic thriving of all the key stakeholders
Employee engagement and communication are prioritized to promote effective collaboration
Recommendation on the Most Suitable Model
It should be noted that each of the approaches above has unique advantages, and ideally healthcare providers need to adopt an integrated approach that allows them to use more than one model. This thinking has possibly influenced the Solutions Center Project. Regarding their relative advantage, however, Solutions Center Project would work best with the care coordination model. As designed, the project places the utmost value on stakeholder engagement and coordination so as to realize the best outcome for the patient. The arrangement is in line with the care coordination model, which recommends coordination of key players and making timely referrals to promote the best health outcome and limit readmission.
The patient-centered approach may not be the best because it makes the patient be the leading active player , thereby downplaying the role of other stakeholders. The project stands for a broader scope of engagement; the project calls for the active participation of all the main stakeholders. Similarly, transition model is not the most suitable approach. While the project also provides for follow-up as anticipated in transition model, strong emphasis on stakeholder involvement before and after medication makes care coordination model a better approach.
References
Fontanarosa, P. B., & McNutt, R. A. (2013). Revisiting hospital readmissions. JAMA, 309(4), 398-400.
Kripalani, S., Theobald, C. N., Anctil, B., & Vasilevskis, E. E. (2014). Reducing hospital readmission rates: current strategies and future directions. Annual review of medicine, 65, 471-485.
Morando, F., Maresio, G., Piano, S., Fasolato, S., Cavallin, M., Romano, A., ... & Destro, C. (2013). How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists. Journal of hepatology, 59(2), 257-264.
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