Transition Care Program for CHF patients mary naylor’s transitional care model

4. project description/ methods- detailed discussion of the plan for conducting the project. must be in apa format and include reference listing. • project plan (a step by step plan of what the project will entail. write in a way that the project could be replicated.) o inputs: the resources that go into a program (including community partners, budget, personnel, other resources….) o outputs: the activities the program undertakes o timeline • project analysis/ evaluation plan o measures: write about how you intend to evaluate each objective. make sure measures align with the objectives. if you are using a survey, state the reliability and validity of the instrument. attach a copy of the instrument. (make sure you obtain permission to use the instrument, if needed, and state this in the proposal). o data analysis plan: write a paragraph about what statistical software program and statistical tests will be employed to examine for change (if applicable). o outcomes: the changes or benefits that you expect. this should include specific program outputs, demographic information, and program evaluation components such as anticipated health outcomes expected as a result of the program. be sure that each outcome measure aligns with the project objectives. o plan for sustainability 5. summary/conclusion • summary of key facts • potential impact on practice • policy implications • future directions • conclusion • must be in apa format and include reference listing. 6. required documents in either body of proposal or as appendices (following apa format) • budget • timeline
Problem and Purpose Statement
The available evidence shows that approximately 5.7 million U.S citizens are suffering from heart failure and this is projected to increase by 46% by 2030 (Ziaeian & Fonarow, 2016). This implies that by the end of 2030 more than 8 million Americans will be living with the chronic disease (Ziaeian & Fonarow, 2016). Congestive Heart Failure (CHF) causes 12 to 15 million hospital consultation visits in the United States every year and is associated with 6.5 million hospital days every year (“How to Reduce Heart Failure Readmission Rates: One Hospital’s Story,” 2018). One of the national priorities in the United States is reducing hospital readmissions. Statistics show that about 20% of the patients under the Medicaid program are readmitted back to the hospital within just 30 days after the initial discharge (Bradley et al., 2013). These hospital readmissions are incredibly costly to the Americans forcing them to spend more than $15 billion annually (Bradley et al., 2013). Therefore, the problem is significant in clinical settings and establishing ways of addressing it will be useful.
According to a research conducted by Saunders & Blanchette (2016), the CHF readmission rate in North Carolina is 19.28 per 10, 000 individuals. In 2016 the local hospital, First Health of the Carolina conducted community needs assessment and carried out analysis of inpatient admissions and readmission rates for chronic diseases. The FY15 data obtained showed that 2, 2202 patients were suffering from chronic conditions (“FirstHealth Moore Regional Hospital,” 2016). Out of these statistics, 8.5% of the patients were readmitted within 30 days of discharge. The members of the Medicaid program portrayed the highest readmission rate (10.3%), and this was followed by Medicare program which recorded a rate of 7.3% and then self-pay (7.6%) (FirstHealth Moore Regional Hospital, 2016). Additionally, it was also found that the Transition Care Clinics established in every county considerably assisted in eliminating the readmission rates for CHF from 2012-2016 (“FirstHealth Moore Regional Hospital,” 2016).
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