DESIGN FOR CHANGE PROPOSAL Re-hospitalization of older adults has become prevalent in most of the health facilities in Canada, posing financial challenges for the health system as well as the older adults. Besides the rise in healthcare expenses that emanate from this problem, readmissions lead to other health-related challenges. The health issues that are related to readmissions include functional disintegration and increased mortality cases. Concerning the cost of readmission, the Canadian health system spends more than $1.8 billion annually due to readmissions. This has reached an alarming level, and prompt measures need to be taken to elevate the problem. Apparently, in the past decade, the Canadian population has increased by roughly 16%, but the number of Canadian hospital beds has not increased in significant percentages. Therefore, with constant hospital readmissions, the quality of care reduces significantly. In fact, one of the indicators of an institution’s inability to offer quality care is a high rate of readmissions. With the desire to enhance the satisfaction of adult patients, health facilities should understand that patient’s comfort correlates directly with lower readmission rates (Philp, Mills, Long, Thanvi & Ghosh, 2013). Therefore, to improve patient outcomes, it will be imperative to adopt a change model in the health facility that will ensure reduced older adults’ readmissions and offer more capacity within the existing resources.

Overview of the Change Model

First, the integration of services will take quite a long time between five and ten years, but some immediate targeted changes can be implemented on the system and processes of care within the health facilities. These changes will not be dependent on a sustained and consistent political leadership as is the case for the huge system changes. Therefore, they will have a more immediate effect on the quality of care extended to the older people, preventing their constant re-hospitalization and length of stay in the health facilities (Kripalani, Theobald, Anctil & Vasilevskis, 2014). Older people require a balance in both their health care and social care, and therefore a model that takes into account improvements in the communication modalities and coordination of services will be essential (Futoma, Morris & Lucas, 2015). Additionally, the change model should take into account the need to incorporate access to robust, reliable and up to date patient data. Therefore, information systems adopted by the health facilities have to be current with the health records and social needs of the patients. Another factor that the change model will have to incorporate is the input of specialist geriatricians who will offer regular, timely and focused case reviews on the status of the older persons. Readmission of the elderly people especially within the next 30 days in the ” Predictive Modeling” that features modalities can be minimized through discharge planning, discharge nurses, patient education and follow up activities (Futoma, Morris & Lucas, 2015).

The predictive modeling approach is essential since it allows nurses to offer care in a patient-centric manner. With the adoption of the modalities presented in predictive modeling, health care providers will have access to information that may influence readmissions. They include age, sex, whether patients have primary caregivers at home, the number of acute admissions that the patient has had over the past six months and the current clinical conditions of the patient. Additionally, the systems factors will be explored which include hospital effects such as the hospital’s length of stay variance and the size of the hospital. They can cause early discharge of patients several other readmissions (Shrader, 2014). Lastly, predictive modeling will factor in some of the community effects facing the client such as the rural residence of the older person, as well as the income and socio-demographics of the neighborhood where the patient lives.

The database to ensure that readmissions are tracked...

As stated, several issues act as drivers for the readmissions of older people such as discharging them before they have fully recovered, older persons misunderstanding their instructions, and cases of new diagnoses. They also include the lack of primary care physicians at home and existence of chronic health conditions refusing to effect changes in behavior (Philp, Mills, Long, Thanvi & Ghosh, 2013). Older people suffering from heart failure and cognitive disorders are the most common to have unplanned readmissions.
Overall, the older persons account for the highest number of readmissions in hospitals both in Canada and in the United States. In Canada, alone on in every twelve patients who have been discharged from the healthcare facilities is readmitted within thirty days. Approximately ten percent of all persons treated in the hospitals come back with related health complications. In fact, statistics show that within 30 days of discharge, Canada faces more than 180,000 readmissions. The population that is at high risk to these readmissions is the older adults, especially those who have dementia and heart failure (Philp, Mills, Long, Thanvi & Ghosh, 2013).

In my work area, the problem is prevalent by medical personnel are trying their best to mitigate it. Many the older persons who have been discharged from the facility come back with complications related to the health problem they were discharged for. In a count of ten older adults, f of them are readmitted to the facility, which calls for interventions to reduce the prevalence of these readmissions. In fact, when I interviewed several of the older people who were readmitted, they pointed out that the hospital was incompetent in service delivery since most of the reason they were admitted for were avoidable. According to them, nurses do not offer elaborate guidelines when they are discharging them, especially the need for dietary measures and educating their primary caregivers. Another issue that arose was the fact that some of the patients especially those that had undergone surgery were dismissed earlier than it was necessary, resulting in bleeding or excessive pains on their wounds.

Stakeholders

I will be the leader of the team that will push for the implementation of the change proposal. I will coordinate the team, running appropriate checks on the various segments of the change process to ensure that the program runs smoothly. My team will be composed of duty nurses, pharmacists, primary caregivers to the older adults, older adults admitted and those ready for discharge as well as the hospitals’ electronic records manager.

Responsibilities of the Team Members

My role as the team leader will be coordinating the rest of the team to ensure that each one of them follows the program keenly. I will ensure that they execute their specific roles, as I also offer substantial guidelines and help across the board since I understand most of the sections of the change design. Firstly, the hospital’s electronic records manager will be tasked with updating information regarding the patients, to ensure that every healthcare professional involved in the care delivery for the patients can access this information. It is a discovery segment of the ACE STAR model of knowledge transformation. With a pool of information regarding the patient’s health status, readmissions, and social, economic issues that the patients have recorded, healthcare professionals will be able to offer focused care and discharge planning for the patient.

The duty nurses will be able to access the electronic information regarding the patient and access the doctor’s report on the condition of the patient to…