Decreasing Readmissions in Medically Complex Children

Practice Problem: There was a report of an existing practice problem of increased 30-day readmission rates in medically complex children at an outpatient clinic within an extensive hospital system. Hospital readmissions can cause clinical, social, and financial burdens to the patients and their families and thus reflected a need for interventions to reduce readmissions. PICOT: The PICOT question that guided this change project: In medically complex pediatric patients ages 0-17, what is the effect of a discharge intervention bundle in reducing all-cause 30day hospital readmissions compared to current practice within an 8-week timeframe? Evidence: The literature revealed 18 pertinent studies that fit the inclusion and exclusion criteria that promoted a discharge intervention bundle. The themes within the evidence included postdischarge telephone calls, follow-up appointments, medication reconciliation, and education with teach-back to reduce overall readmission rates. Intervention: The evidence-based intervention utilized the bundle of post-discharge telephone calls within 72 hours, follow up appointments within 7 days, and medication reconciliation with education and teach-back through in-person and virtual care. The clinic nurses championed the intervention and tracked all the data using a check sheet. Outcome: Evaluation of the outcome measures confirmed a decrease in all-cause 30-day readmissions from 23% to 14.5% within the project timeframe. Implications of the findings support the existing evidence for implementing a multifaceted bundle to decrease readmissions. Conclusion: The evidence-based change project decreased all-cause 30-day readmissions rates. The results of the project proved that implementing consistent discharge standards in medically complex children helped guide medical staff, improved patient outcomes, saved costs to the organization, and reduced 30-day all-cause hospital readmissions. DECREASING PEDIATRIC READMISSIONS 4 Decreasing Readmissions in Medically Complex Children All-cause hospital readmissions are considered a measure of quality in organizations across the country (Shermont et al., 2016). In the United States, the Affordable Care Act (ACA) was established to improve quality of care by supporting transitional care services, decreasing preventable hospital readmissions, and improving healthcare savings (Verhaegh et al., 2014). One program that supports the ACA is the Hospital Readmissions Reduction Program (HRRP), a value-based purchasing program that links the quality of care to payment based on readmission rates (CMS, n.d.). The program focuses on adult patients who are readmitted to the hospital with specific diagnoses such as myocardial infarction, heart failure, and chronic obstructive pulmonary disease. In recent years there has been an increased effort to reduce readmissions not only in adults, but also in medically complex children by implementing discharge interventions post hospitalization (Brittan et al., 2015; Coller et al., 2015; Coller et al., 2017; Finlayson et al.,2018). According to Coller et al. (2017), medically complex children were only 1% of the pediatric population but used a consumed third of all child healthcare spending (p. 381). Children with medical complexity often have multiple medical problems which require specialists, equipment, and high acuity of care (Stephens et al., 2017). This puts them at a greater risk of hospitalization, readmission and undesirable outcomes (Brittan et al., 2015). The purpose of this project was to implement a post-hospitalization discharge bundle that includes telephonic followup, outpatient or virtual follow-up appointments, medication reconciliation, and the teach-back method with patients and families to reduce all-cause 30-day hospital readmissions. The Department of Health and Human Services (HHS, 2020) has made policy changes during the COVID-19 emergency to allow health care providers the opportunity to use HIPAA-compliant DECREASING PEDIATRIC READMISSIONS 5 video communication such as Doxy.me to perform virtual visits for patients who cannot be seen in person. These virtual visits were utilized for the project as needed. Significance of the Practice Problem According to Bailey et al. (2019), the national rate of 30-day all-cause readmissions of patients older than one year of age in 2016 was 12.3% for Medicaid, 10.8% for private insurance, and 7.9% for uninsured (p.3). The average cost of all-cause 30-day hospital readmissions for all diagnoses was $12,500 (p.7), while the average cost for children with congenital malformations was as high as $19,000 per readmission (p.8). Furthermore, at the facility this project was conducted, the 2019 overall all-age, all-cause 30-day readmission rate was 15.3% (Hospital Care Data, n.d.). This was consistent with the national average of 15% (Robert Wood Johnson Foundation [RWJF], 2013). Based on data from the Children’s Hospital Association, the organization pediatric overall 30-day, all-cause readmission rate from 2019 was 10%, slightly lower than the national average of 11% (J. Mahla, personal communication, January 31, 2020). The Chronic Complex Clinics (CCC) overall 30-day, all-cause readmission rate from 2019 was 23%, much higher than the national average of 11% (B. Bavinger, personal communication, February 11, 2020). Though these statistics do not show the full impact of readmissions on the organization, clients, and their families, they revealed the need for further implementation of interventions to reduce overall hospital readmissions. Hospital readmissions cause clinical, social and financial burdens that are significant to the patient and family due to the cost of care, lost time at work and school, developmental effects for chronically ill children, and increased potential for hospital-acquired infections (Nakamura et al., 2014). Comorbidities, race, socioeconomic factors, access to healthcare, and chronic conditions are all factors that increase the risk of readmission (Flanagan et al., 2017). Some legal DECREASING PEDIATRIC READMISSIONS 6 and ethical factors considered were how prolonged hospitalizations and readmissions link to patient stress, poor results, and increased mortality (Mindru et al., 2016; Rosman et al., 2015). Initiation of discharge interventions to improve transitions and prevent pediatric hospital readmissions were essential for medically complex children and their families.


Outcome
The intended outcome of this project was a decrease in hospital readmissions of medically complex children over the eight-week project timeframe. The nurse champions were taught about discharge interventions, and their knowledge was tested using a pre-and postconfidence test within two weeks of the start of the project. A script for the nurses was provided for them to use while speaking with patients, to ensure that the calls were uniform and all pertinent information was gathered. Additionally, a telephone call and other interventions in the discharge bundle were added as part of the electronic health record to track data and assist in standardizing the intervention process.
This work was important because annually pediatric hospital readmissions accounted for 18.8% of all admissions, which lead to more than 3.4 billion of all annual inpatient charges (Shermont et al., 2016). The 2019 CCC readmission rate was 23% (B. Bavinger, personal communication, February 11, 2020). The desired outcome of this project was to reduce the rate in the population that receives the discharge bundle, helping it meet the national average of 11%.

Timeframe
The duration of this project was eight weeks. Implementation of the project started after the University Evidence-Based Practice Review Council (EPRC) and the facility Institutional Review Board (IRB) approved the project. The project took place within the CCC. Once completed, a review of the pre-and post-discharge intervention bundle was conducted.

Evidence Based Framework and Change Theory
Healthcare is constantly changing, and nurse leaders play integral roles in promoting change by innovating and implementing new evidence into practice. Hospital readmissions are considered a measure of quality in organizations across the country, and interventions should be taken to prevent readmissions (Shermont et al., 2016). The literature supported implementing discharge interventions post hospitalization to reduce readmissions (Brittan et al., 2015;Coller et al., 2015;Coller et al., 2017). Nurses used the Plan, Do, Study, Act (PDSA) framework (Knudsen et al., 2019) and Lewin's Change Theory (Batras et al., 2016) to identify possible resistance and strengths prior to implementing interventions to reduce hospital readmissions in medically complex children.

Evidence Based Framework
According to Knudsen et al. (2019), the PDSA framework has been used in evidencebased projects to identify weaknesses and plan changes to correct those weaknesses. The PDSA framework was chosen to guide this project which aimed to decrease hospital readmissions in medically complex children. The "plan" step was the first in the framework and was used to identify problems and to propose a change (Sylvia & Terhaar, 2018). Typically, this step is accomplished by forming a project team and by setting roles, timelines and measures for successful completion. Next, to fulfill the "do" step, the intervention was carried out and evaluated to determine whether the response was successful (Sylvia & Terhaar, 2018). Furthermore, the "study" step could be used during the intervention to make rapid adjustments (Sylvia & Terhaar, 2018). This could also occur after the intervention has been carried out; the team worked together to understand the results and to determine if the objectives to improve outcomes were met. The final step is the "act step," wherein a decision was made to sustain the changes or to develop a new plan (Sylvia & Terhaar, 2018).

Change Theory
Lewin's Change Theory was used to guide the organizational changes to reduce 30-day all-cause pediatric hospital readmissions in medically complex children. Hussain et al. (2018) reported that Lewin's Change Theory identified three stages an organization must go through to make change become part of a system: unfreezing, moving, and refreezing. The three stages focus on making permanent changes to reach desired outcomes (Hussain et al., 2018). The goals of this theory are to identify the problem, collaborate on the best solutions, plan a change, and implement that change into practice (Hussain et al., 2018). Batras et al. (2016) noted that Lewin's unfreezing stage interrupts the status quo of an organization, identifies a problem, and weighs the benefits of change against the negatives of the process. Nurses can lead the change initiative by strengthening driving forces, obtaining support, and getting buy-in from fellow nurses to reinforce change (Hussain et al., 2018). Movement, the second phase of Lewin's Change Theory, occurs when interventions take place. Once the benefits of the change are realized and doubts are removed, then the organization and staff can support the change. The movement phase allows the organization to implement the change while making improvements along the way to best serve the organization (Batras et al., 2016).
Refreezing, the final phase, occurs when the intervention has transformed the organization in the areas where it was implemented, forcing accommodation. The change will become the new routine and should reinforce behaviors to promote sustainability (Batras et al., 2016).
This project targeted the implementation of an evidence-based discharge intervention bundle to reduce hospital readmissions. For the interventions to be successful, the organization and providers must change the way they handle hospital discharges. The PDSA framework (Knudsen et al., 2019) and Lewin's Change Theory (Batras et al., 2016) guided the implementation of interventions to promote successful change within the organization. Furthermore, a hand search was conducted using reference lists in several related articles. All the searches included were peer-reviewed, academic journals, published within the last five years, in the English language. All the searches used 2015-2020 as the time frame for inclusion criteria.

Literature Search Results and Evaluation
The initial search yielded 22,526 citations as follows: CINAHL, 81 citations; ProQuest, 18,732 citations; and PubMed, 3,713 citations. The following inclusion criteria were added: (a) interventions to reduce readmissions to an acute care hospital; (b) and discharge interventions post hospitalization. Duplicates were merged, and articles excluded included editorials, periodicals, and commentaries. After inclusion and exclusion were applied, 374 citations remained as follows: CINAHL, 49 citations; ProQuest, 281 citations; and PubMed, 44 citations.
The titles and abstracts of the 374 articles were reviewed for relevance to PICOT. All studies were screened, and if they met eligibility criteria, the full text was retrieved and evaluated to determine final admissibility. Ultimately, a total of 18 articles were selected to identify the main themes within the literature to reduce 30-day all-cause readmissions in medically complex children.
The final literature review included a thorough evaluation and comparison of the 18 articles to identify evidence-based interventions for reducing hospital readmissions in medically complex pediatric patients. Synthesis of the literature identified consistent evidence-based support of four main interventions: post discharge telephone calls, post discharge outpatient follow-up, medication reconciliation, and education with the teach-back method. A summary of primary articles (see Appendix A) and systematic reviews (see Appendix B) includes the evidence-based bundle interventions to reduce readmissions which will be reviewed below.
The evaluation of the 18 articles retrieved from the literature review utilized grading from the Strength of Recommendation Taxonomy (SORT) to assess the quality of the entire body of evidence. The review of literature finds multiple experimental and non-experimental studies that are consistent with SORT Level 1, a high level of evidence, with good quality findings. There were some Level 2 articles as well due to small sample sizes, non-blinding, and no statistical significance. The overall grade of the body of evidence was a B, which has a moderately strong recommendation for practice (SORT, 2020).

Themes from the Evidence
The literature was evaluated for similar ideas and results. Synthesis of the literature identified consistent, evidence-based support of four main interventions to support a discharge bundle, including post discharge telephone calls, post discharge outpatient follow-up, medication reconciliation, and education with the teach-back method.

Post Discharge Phone Calls
In the literature, the most frequently cited intervention for reducing hospital readmissions in medically complex children is a post discharge telephone call. Multiple articles agreed that the recommendation to provide a post discharge telephone call should be completed shortly after hospitalization (Auger et al., 2018;Branowicki et al., 2017;Coller et al., 2018;Flippo et al., 2015;Hoyer et al., 2018;Oscalices et al., 2019;Phatak et al., 2016;Yiadom et al., 2018).
Several approaches regarding the right time to deliver post discharge phone calls are presented in the literature, including a phone call within 48 to 72 hours after discharge to reduce readmissions and reinforce discharge teaching (Auger et al., 2018;Flippo et al., 2015;Hoyer et al., 2015;Phatak et al., 2016;Yiadom et al., 2018). Oscalices et al. (2019) suggested a phone call within seven days of discharge, conversely Branowicki et al. (2017), andColler et al. (2018) did not discuss a specific time frame for the intervention. These studies provide precise, significant efforts of post discharge telephone call recommendations to reduce hospital readmissions despite the differences noted in the time frames.
Recommendations from the Agency for Healthcare Research and Quality (AHRQ, 2013) supported the Re-Engineered Discharge (RED) tool, which was aimed at improving patient discharges from the hospital by increasing patient and family satisfaction and decreasing hospital readmission rates. According to RED, the phone call should take place two to three days after discharge by clinical staff and should review patient's health status, medicines, appointments, home services and plans for protocols in the case that problems arise (AHRQ, 2013). The clinician making the call should become familiar with the patient by thoroughly reviewing all information about the hospital stay and provide education with the teach-back technique to ensure that the patient understood what was explained (AHRQ, 2017).

Education with Teach-back
In addition to post discharge telephone calls, patient and family education with the teachback method is used in the hospital and after the patient is discharged to reinforce care and reduce readmissions (Almkuist, 2017;Coller et al., 2018;Hamline et al., 2018;Shermont et al., 2016;Yiadom et al., 2018). Shermont et al. (2016) suggested that the teach-back methodology be implemented by all staff to support the improvement of patient education. Furthermore, Coller et al. (2018) suggested using the teach-back method on patients that receive action plans and during post discharge phone calls to identify any gaps that could lead to future hospitalization. Rice et al. (2018) recommended a nurse-led patient education program that provided written and verbal education to patients either in person or on post discharge telephone calls to reduce readmissions without mentioning the use of the teach-back methodology. While the studies above used several approaches to implement the teach-back methodology, it has proven successful to patient care and aids in reducing readmissions.
A group of experts created the Seamless Transitions and Readmissions Network (STARNet), a consensus document that focuses and informs about transitions from hospital to home for children with medical complexity (Auger et al., 2015). The consensus reported that for pediatric populations, discharge interventions such as inpatient tailoring and education with teach-back methods were proven to prevent subsequent hospital utilization. The expert panel consensus also supported the interventions of medication reconciliation, care coordination, and primary care follow-up visits despite contradictory evidence in preventing 30-day readmissions.
Furthermore, the panel suggested further research in the future for the medically complex pediatric patients in reducing readmissions (Auger et al., 2015).

Outpatient Follow-up
Outpatient follow-ups after hospitalization were a common theme in the literature for reducing hospital readmissions (Brittan et al., 2015;Christensen & Payne, 2016;Coller et al., 2018;Hamline et al., 2018;Hoyer et al., 2018;Kamermayer et al., 2017;Shermont et al., 2016). Brittan et al. (2015) conducted a study specifically on follow-up visits and readmissions in medically complex children. The study had a positive association with early post discharge outpatient follow-up between four to 29 days after discharge. Conversely, children who followed up within three days were more likely to be admitted. Some of the literature focused on discharge bundles, which included outpatient follow-up to reduce readmissions (Coller et al.,2018;Hamline et al., 2018;Kamermayer et al., 2017;Shermont et al., 2016). These studies evaluated outpatient follow-up along with medication reconciliation and discharge education with the teach-back method. While none of the studies listed a time interval for outpatient follow-ups, they all showed improvement in reducing readmissions (Coller et al., 2018;Hamline et al., 2018;Kamermayer et al., 2017;Shermont et al., 2016). Another study used transition guides for patients at high risk for readmission. This was accomplished using individualized care by reinforcing discharge instructions, performing medication reconciliation, ensuring provider follow-up as well as arranging transportation if needed, which resulted in reduced readmissions (Hoyer et al., 2018).

Medication Reconciliation
Medication reconciliation and management were frequently brought up in the literature within discharge bundles and care transitions to help reduce 30-day readmissions (Coller et al., 2018;Hoyer et al., 2018;Phatak et al., 2016;Shermont et al., 2016). Most of the literature supported the use of bundles that included medication reconciliation and management post discharge along with other interventions to reduce 30-day readmissions (Coller et al., 2018;Hoyer et al., 2018;Shermont et al., 2016). One study used pharmacists to provide patients with face-to-face medication reconciliation, pharmaceutical care plans, discharge education counseling, and post discharge telephone calls, which also showed positive results in decreasing 30-day readmissions to the hospital (Phatak et al., 2016).

Discharge Bundles
Evidence from the literature supported the implementation of multifaceted discharge bundles for the use of reducing hospital readmissions (Coller et al., 2018;Kamermayer et al., 2017;Shermont et al., 2016;Stephens et al., 2017;Zhu et al., 2015). The majority of these studies which focused on discharge bundles used four interventions to reduce 30-day readmissions: medication reconciliation, patient education with teach-back, timely outpatient follow-up, and post discharge telephone calls (Coller et al., 2018;Kamermayer et al., 2017;Stephens et al., 2017). Shermont et al. (2016) also used these interventions but left out the post discharge telephone call, while Zhu et al. (2015) recommended home visits be added to the intervention bundles.
A key driver framework developed by experts introduced strategies to reduce hospitalization of children with medical complexity (Coller et al., 2017). The panel determined four intervention strategies to have the highest effectiveness rating for reducing hospitalization: (a) enhanced provider access such as 24/7 phone coverage and easy access to follow-up care, (b) early recognition and contingency plans made at outpatient and inpatient visits, (c) caregiver knowledge and skill enhanced with intensive coaching and education with teach-back, and (d) care transitions of standardized discharge plans, follow-up plans, post discharge telephone calls, and home visits (Coller et al., 2017). This framework supported the use of discharge bundles to reduce hospital readmissions in medically complex children.

Practice Recommendations
The literature review sought to answer the PICOT question by determining that the implementation of a discharge bundle was effective in reducing 30-day all-cause hospital readmissions in medically complex children. Based upon the results of the evidence found in the literature review, the practice change recommendation included implementing a discharge bundle with the following interventions: (a) post discharge telephone calls, (b) post discharge outpatient follow-up, (c) medication reconciliation, and (d) education with the teach-back method (Coller et al., 2018;Kamermayer et al., 2017;Shermont et al., 2016;Stephens et al., 2017;Zhu et al., 2015).
The primary evidence review revealed six randomized control trials, two cohort studies, and one exploratory, observational, and quasi-experimental study. The review of these studies found multiple experimental and non-experimental studies that are consistent with SORT level one, a high level of evidence, with good quality findings. There were some level two studies, and the overall grade of the body of evidence is a B, which represented a moderately strong recommendation for practice recommendation (SORT, 2020).
Supporting evidence, including a key driver framework, expert consensus, and the AHRQ RED toolkit, which validated the recommendation of discharge bundle interventions to reduce all-cause 30-day readmissions in medically complex children (AHRQ, 2013;Auger et al., 2018;Coller et al., 2017). The Institute for Healthcare Improvement (IHI, 2017) recommended the use of the SMART Discharge Protocol (Signs, Medications, Appointments, Results, and Talk with me) to improve care for patients and their families regarding discharge procedures. The use of the protocol improved transition processes including care coordination, enhanced coaching with education, and self-management, which aligned with the discharge intervention bundle to make a strong practice recommendation based upon the evidence (IHI, 2017).

Project Setting
The CCC is a pediatric primary care office located within a large hospital-based health system for medically complex children and provides primary and acute care services, serving as a medical home for approximately 1,000 patients (BayCare, n.d.-c). The patient population is children 0-17-years of age. Primary staffing for the clinic included an office manager, RNs, licensed practical nurses, physicians, nurse practitioners, a unit secretary, a care coordinator, a social worker, a child life specialist, a counselor, and a behavior specialist. Additionally, secondary staff included: housekeeping, pharmacy, facilities and lab personnel. The clinic is part of a leading not-for-profit health care system with over 15 hospitals and 380 medical locations within a four-county area (BayCare, n.d.-c).

Organizational Structure
The CCC is located within a nonprofit corporation that operates a $2.6 billion-integrated health care delivery system in a four-county region (BayCare, n.d.-b)The organization has five clinical divisions and is the largest hospital division in the region. Additionally, the organization includes acute care hospitals, long-term care facilities, free-standing rehabilitation centers, urgent care centers, imaging facilities, ambulatory surgery centers, wellness centers, a physician network, retail pharmacy, and comprehensive home health agency (BayCare, n.d.-b). Its organizational structure is different compared to many other health care organizations, being that it is organized by divisions rather than individuals, including hospital, physician, ambulatory, behavioral health, clinical integrated network, supply chain division, and system office (BayCare, n.d.-b).

Organizational Culture
The organization's mission statement is, "Our Health System will improve the health of all we serve through community-owned health care services that set the standard for highquality, compassionate care" (BayCare, n.d.-b). A major part of the organization's culture is that they do not have a hierarchy within the system. Instead, they have a leadership team available to all employees who are considered valuable, regardless of their job title (BayCare, n.d.-b).

Organizational Need
An organizational needs assessment was performed, and it identified a high readmission rate in medically complex pediatric patients that were statistically much higher than the national average (B. Bavinger, personal communication, February 11, 2020). The Five Why's Tool was used to address the issue of a lack of discharge interventions to reduce hospital readmissions (American Society of Quality [ASQ], n.d.). The results showed a lack of knowledge by the organization, providers and families, along with costs associated with the interventions, and a lack of time to perform interventions. Furthermore, organizational and quality tools from the ASQ, (n.d.) were instrumental in planning the evidence-based practice change. The tool was used to identify gaps such as the knowledge deficit in the facility, in order to address and facilitate the discharge intervention bundle and improve hospital readmissions for medically complex pediatric patients.

Stakeholders and Support
Key stakeholders interested in the project to reduce all-cause 30-day hospital readmissions included the hospital's leadership team, the medical director of the CCC, the director of the children's hospital, and the chief nursing officer who all supported the project.
Additional stakeholders included the patients, their families and the clinic staff. The staff in the CCC consisted of a physician, nurse practitioner, RNs, a licensed practical nurse, a social worker, care coordinators, a unit secretary, and a child life specialist. Furthermore, a preceptor sponsored this project.

Sustainability
Sustainability is an important aspect of any successful project and is often associated with organizational success. Some factors that can facilitate sustainability in healthcare organizations include funding, political environment/context, organizational capacity, leadership, staff training, and adaptability (Crespo-Gonzalez et al., 2020). Educational reinforcement with continuing education and evaluations on the discharge bundle helped to sustain the project. Adding the interventions into the existing electronic medical record provided easy access to patient readmission rates and past hospitalization information to aid the project.

Interprofessional Collaboration
Interprofessional collaboration was an integral part of discharge bundle to reduce 30-day all-cause readmissions in medically complex children. The clinic's team was educated on the project and worked cohesively together. The team involved in the project implementation was comprised of a physician, nurse practitioner, RNs, care coordinator, and unit secretary.
Interprofessional education for the team on the evidence-based project was done to increase their knowledge of why and how the coordination of post hospitalization interventions should run.

Strengths, Weaknesses, Opportunity, and Threat Analysis
A Strengths, Weaknesses, Opportunities, and Threats (SWOT) tool has been used as a form of analysis to examine industries, organizations, products, and individuals (Ojala, 2017).
Strengths and weaknesses often exist internally within a company or organization, while opportunities and threats happened outside of the facility (Ojala, 2017). Ultimately, a SWOT analysis was completed to determine the organization's ability to implement change (see Appendix C).
First, an identified strength was that leadership and the staff of the facility were committed to the change. Additionally, excellent communication by the staff and resources for the project were available. However, an identified weakness was resistance from patients after hospitalization to follow-up and answer phone calls. A further challenge was scheduling time to educate staff on the interventions and to incorporate them into daily routines. A potential significant weakness could have been the lack of bilingual staff to converse with our Spanish speaking patients, though this did not end up being a problem. This project created the opportunity to reduce readmissions and decrease costs while improving satisfaction and overall care. Factors that could have threatened the interventions would have been staff turnover, poor discharge planning, and non-compliance. The knowledgeable CCC staff managed all threats.

Project Overview
The vision, mission and objectives of the evidence-based practice change conveyed its intent and purpose. The mission defined the organizations purpose, while the vision focused on the goals and aspirations of the project. The primary objective of the project was to reduce allcause 30-day hospital readmissions in medically complex children. It was accomplished through a variety of short-and long-term goals. Unintended consequences and risks were evaluated for the project to promote success and sustainability.

Project Vision and Mission
The vision for this evidence-based project was to reduce the all-cause 30-day hospital readmission rates of medically complex children from 23% to 11%, to meet the national average (J. Mahla, personal communication, January 31, 2020). The mission of this project was to implement a multifaceted discharge bundle within the CCC. It was anticipated that a decrease in hospital readmissions would result in improved patient quality of care and outcomes. The project's vision and mission were congruent with those of the hospital to "improve the health of all we serve by providing high quality, compassionate care" (BayCare, n.d.-b). The objectives of the project are discussed in more detail below.

Objectives
The objective of this project was to reduce the all-cause 30-day hospital readmission rates in medically complex children. In 2019, the 30-day readmission rate for pediatrics at the Children's Hospital was 10%. The rate for the CCC was 23%, and the objective was to lower this number toward the national average, which is 11% (J. Mahla, personal communication, January 31, 2020). Short-and long-term goals are discussed in more depth below.

Short-Term Goals
There were two short-term goals identified for this project. The first was to collaborate with all stakeholders prior to the implementation of the discharge bundle intervention. The second short-term goal was to educate and train all CCC staff on the elements of the discharge bundle within the first two weeks of the project. These goals were met as planned and the team was able to reiterate and demonstrate all aspects of the discharge bundle. A post-education confidence test was given to staff to evaluate whether the education was effective. Additionally, the team was trained for and able to use the RED toolkit for post discharge telephone calls to aid effective communication with families within the project's eight weeks (AHRQ, 2013).

Long-Term Goals
The long-term goal of this evidence-based change project was to reduce the CCC allcause 30-day hospital readmission rates in medically complex children from the current rate of 23% to 11%, the current national standard identified by the Children's Hospital Association (J. Mahla, personal communication, January 31, 2020). Another long-term goal was for clinic staff to continue annual education related to the discharge bundle to sustain the change. Once the project was completed, a long-term goal would be to implement the bundle across the organization to promote a facility-wide quality change and reduce hospital readmissions in pediatric patients.

Unintended Consequences and Risks
While this evidence-based project was intended to benefit the organization, operations were still vulnerable to minimal risks and had to be evaluated. Some barriers and risks associated with this evidence-based project included resistance to change from staff and patients, ineffective communication between staff and patients, challenges in scheduling follow-up appointments, problems with post-discharge phone calls, and ineffective interprofessional collaboration among specialists. Recognizing these risks early provided the opportunity to develop a staff communication system that gave frequent project updates (Kogon et al., 2015). Another strategy to mitigate miscommunication was to inform all patients who attended an appointment at the CCC within the allotted time frame of the discharge bundle and associated expectations.
Ultimately, being proactive with staff and patients helped to minimize the risk associated with the project. Furthermore, some unintended consequences related to this project could have been decreased ED utilization, increased primary care utilization, and increased patient and family satisfaction. While most unintended consequences could be viewed as unfavorable, these were positive consequences to be considered.

Project Plan
Lewin's Change Model guided the planning for this evidence-based change project. It was chosen because it is a logical model to promote successful change within organizations (Batras et al., 2016). Additionally, the PDSA model was used successfully in a QI initiative with similar interventions that reduced pediatric readmissions using a discharge bundle combined with teach-back methodology, which indicated using change models such as Lewin's and the PDSA model could effectively promote practice change (Shermont et al., 2016). This project plan included the steps of the change model and the sequencing of steps designed to implement change. The model also allowed the project manager and stakeholders to identify barriers and facilitators to the project. The project's schedule, needed resources, and budget were considered and reported. Discharge intervention bundle steps will be systematically described using the PDSA model. Lastly, the role of the project manager, leadership skills, and interprofessional collaboration were essential to the success of the change project.

Lewin's Change Model
Lewin's Change Theory was used for this project, since it has been proven to be successful in guiding organizational change (Batras et al., 2016). Lewin's model included three steps: unfreezing, moving, and refreezing (Hussain et al., 2018). The following section explains how each step was used to promote the implementation of the discharge intervention bundle.

Unfreezing
The initial "unfreezing" stage consists of identifying of the problem and weighing the benefits of the change against the risks of the process (Batras et al., 2016). In this stage, all key stakeholders in the implementation were identified. Nurses, administrators, a unit secretary, and the care coordinators were identified. Baseline data from the practice were used to demonstrate the need for change. Nurses led the change initiative while support was obtained by getting buyin from other stakeholders with open communication to reinforce the ability and need for change (Hussain et al., 2018).

Moving
The second step of Lewin's model is the "moving" stage (Hussain et al., 2018). This is when interventions take place and the change process takes hold. Once the benefits of the project are realized and staff can support the change, the "moving" stage initiates. In this step, staff education and implementation workflow of the project occurred within the allotted timeline. This allowed the organization to implement the change, measure results, and evaluate progress.
Ongoing data collection supported making necessary improvements along the way ( Batras et al., 2016). Throughout the "moving" stage, staff were updated on a weekly basis on the progress of the evidence-based project.

Refreezing
The last step of the change model is the "refreezing" stage which occurs after the intervention bundle has transformed the organization in the areas where it was implemented to sustain the change (Batras et al., 2016). To effectively support the practice change, it must become part of the routine of the facility and weaved into the daily operations. Furthermore, continuing education will occur annually to ensure continued improvement.

Intervention
The hospital leadership and CCC had determined reducing readmission to be a priority for change within the organization. The PDSA model was used to guide the implementation of the associated evidence-based project (Sylvia & Terhaar, 2018).
The "plan" phase began with creating an interdisciplinary team. Members consisted of a physician, nurse practitioner, unit secretary, care coordinator and nurses. Additionally, a project charter was created to explain the project plan and establish each team members role and Baseline practice data as well as organizational and national benchmarks were used to demonstrate the problem.
The discharge intervention bundle of early outpatient or virtual follow-up, post discharge telephone call, medication reconciliation, and education with teach-back was shared with stakeholders to create interest and enthusiasm about improving their current practices while reducing readmissions (Coller et al., 2018;Kamermayer et al., 2017;Shermont et al., 2016;Stephens et al., 2017;Zhu et al., 2015). The vision was shared in the first weekly huddle and a fishbone diagram was posted in the employee office to get input from staff and increase involvement in the project. Furthermore, weekly huddles and emails were used for ongoing communication with the team throughout the project.
The evidence-based project began with two training seminars to educate staff about proposed discharge bundle interventions. Following the "do" phase of the PDSA model, this was when efforts to carry out the planned changes began (Sylvia & Terhaar, 2018). Clinic staff were encouraged to participate in educational training, and a conviction and confidence scale was used pre-and post-education. Staff also participated in a teach-back observation tool for inter-rater reliability to determine use of teach-back and competency on the discharge bundle interventions Once the interventions were complete, the "study" step of the PDSA was done. The project manager brought staff involved in the project together to understand the results of the project and to determine if the objective of reducing 30-day readmissions was met (Sylvia & Terhaar, 2018). Post-intervention data were collected and analyzed. Summative and formative evaluations were conducted and are described in more detail in the "Project Evaluation and Results" sections.
The final step of the PDSA cycle was the "act" phase in which the data were analyzed to determine whether the primary objective was met to reduce 30-day all-cause readmissions in the medically complex pediatric patients, and if the project had a positive impact on the organization to support sustainability (Sylvia & Terhaar, 2018).

Barriers and Facilitators
Barriers and facilitators were essential in considering whether it was worth trying to implement a practice change within an organization. Facilitators of the project were those working to move the project forward, such as the DNP student, clinic staff, and nurses.
Organization and administration support were important facilitators of the project's mission, being that they worked to ensure staff participation and assist with education. One possible barrier to the project was patient non-compliance. To anticipate barriers, staff was involved early with the project to address any obstacles and ensure necessary training, staffing and comfort with the project.

Project Schedule
The University of St. Augustine for Health Sciences EPRC approved of the project before efforts to begin commenced. Once this was completed, the hospital required Institutional Review Board approval. Initial steps included proposals to the EPRC and IRB for approval. Once both approvals were received, the interprofessional team was developed, and project details and education were prepared. All baseline data was collected, and education training on the discharge bundle was completed. Staff knowledge was tested using a post-education conviction and a confidence scale. Once implementation of the eight-week project began, data was collected, analyzed, and compared to baseline data. Please see Appendix D for a detailed project timeline.

Resources and Budget
The interprofessional team that supported and helped carry out the interventions were a key resource for this project. Another resource was a space for education training provided by the facility. Lastly, the RED toolkit was utilized during post discharge telephone calls for uniformity (AHRQ, 2013). Funding and budget for the project, although minimal, were presented to hospital administration for approval. The benefits of reducing hospital readmissions for medically complex pediatric patients were disclosed.
There were costs associated with training staff involved in the project.
These consisted of two one-hour trainings for (a) three staff nurses and one nurse practitioner (average wage of $30 an hour), (b) two care coordinators (average wage of $26 an hour), (c) oneunit secretary (average wage of $19 an hour), and (d) the medical director (average wage of $100 an hour) for a total of $582.00. There were additional costs of $300 for educational materials for staff and flyers for the clinic explaining the new discharge bundle intervention. There were also indirect costs to the facility of approximately $125. Please see Table 1 for a full breakdown.

Project Management Leadership
Strong leadership skills are essential in an organization when beginning a change as the project manager. According to Strand et al., (2016), one possibility for managing and mentorship is forming a partnership with team members to set clear goals for change projects and to agree on objectives. Leaders are more successful when they promote mentorship and coaching for team members by setting expectations, developing effective communication, building relationships, and setting timelines to support the change (Rihal, 2017).
The project manager provided coaching by supplying tools to guide team members through the steps of change processes, progress tracking and goals. Adding these mentoring and coaching strategies contributed to successful leadership and organizational success when implementing change (Strand et al., 2016).

Project Evaluation Results
The purpose of a project plan evaluation is to measure success while also identifying any problems (Kogan et al., 2015). During the process of evaluation for this evidence-based project, a detailed exploration of the project's outcomes, impacts and goals were completed. The evaluation was completed to determine whether the implementation of a discharge intervention bundle reduced 30-day hospital readmissions within an eight-week timeframe. The selection of participants is discussed in more detail below, along with the data, reliability, measures, and data collection tools. Formative evaluations were completed throughout the project and summative evaluations were conducted at project completion.

Selection of Participants
Participants were selected for the project based on the inclusion criteria. Participants included CCC patients from 0-17 years-old, who were discharged from the hospital within the project timeframe. Patients of the CCC had two or more chronic pre-existing conditions. The exclusion criteria eliminated patients who were admitted to an outside facility since they could not be easily tracked. No identifiable patient information was collected to protect human rights and healthcare privacy.

Data Details
The plan evaluated the measures associated with the project to answer the PICOT. The data collected included outcome measures: (a) all-cause 30-day hospital readmissions, (b) post discharge telephone calls, (c) post discharge follow-up, and (d) medication reconciliation with education and teach back. Other useful data in analyzing project success included staff, patient and family satisfaction. All data measures are described in the "Categories of Measures" section.

Validity, Reliability, and Data Collection
Validity and reliability were essential in project evaluation (Sylvia & Terhaar, 2018). For project evaluation, validity described whether what was intended to be measured was measured.
Reliability was used to determine the competence of data collection mechanisms to measure what was planned (Sylvia & Terhaar, 2018). Then, quantitative data collection determined the outcomes related to the variables (Sylvia and Terhaar, 2018). Cerner is a reliable and valid electronic medical record and was used for collection of discharge and admission data (CMS, 2020).
Microsoft Excel was used to organize and analyze the pre-and post-intervention data.
The data were entered and double-checked for accuracy. Pre-intervention data were collected using CCC patients discharged from the hospital the eight weeks before intervention implementation. Post-intervention data were collected by using the number of CCC patients who were readmitted to the hospital for any cause within 30-days of discharge throughout the project timeline. The pre-intervention data was then compared to post-intervention data for analysis to determine if objectives were met. To do so, descriptive statistics were used, which were simple summaries of the samples and measures (Sylvia & Terhaar, 2018). Secondary outcome data were collected at 30 and 60 days from the check sheet. The process measure data of patient and staff satisfaction with the bundle were collected by the DNP student at the end of the project. All data were then entered into Microsoft Excel for analysis.

Data Analysis
The project manager consulted with a statistician to analyze and interpret the data related to the evidence-based project. A combination of tests were used to analyze collected data. Data was entered into Excel initially, double checked, and then entered into SPSS program before computing outcomes using a standard 0.05 p-value. An unpaired t-test was used to compare preand post-implementation of 30-day readmissions. As seen in Table 2, there was a statistically significant difference between the score of pre (M=24.81, SD=1.65) and post (M=14.63, SD=1.09) results. The t-value was 35.709, which was significant at alpha= 0.05, resulting in statistically significant differences between the participants' results of preand postimplementation. This proved that the intervention was effective to decrease readmissions in medically complex children.
A paired t-test was used to compare pre-and post-implementation in staff competency on the discharge bundle. As seen in Table 3, there was a statistically significant difference between the scores of pre-(M=30.38, SD=1.06) and post (M=35.25, SD=0.46) results. The tvalue was 12.246, which was significant at alpha= 0.05, resulting in a statistically significant differences between the participants' results preand post-education. This proved that the intervention bundle training to the staff was effective and they were competent in the discharge bundle.
Statistical significance is often determined by assigning a p-value, which is common to determine significant differences between groupings in evidence-based projects (Sylvia & Terhaar, 2018). For this project p -value was <0.05 making the project statistically significant.
However, for evidence-based change projects it is imperative to show clinical significance, which will be discussed in more detail below.

Missing Data and Storage
The initial steps of discharge bundle interventions were well documented and tracked throughout the project's timeline. All measures and outcomes were rolled into documented statistics until the end of the project. Unintended and intended consequences as well as details from any missing data were disclosed in the results. Missing data can occur due to no value entered for specific variables (Sylvia & Terhaar, 2018). This can happen from poor compliance or absences of the staff. Missing data can significantly affect the conclusion drawn from the data.
The team was well educated on the project and the importance of accurately documenting data in the electronic health record to limit missing data.
Only the implementation team had access to the secure CCC shared drive and check sheet. There were safeguards for all information stored on the student's computer, and everything was password protected. All data on the check sheet data collection tool were numerically coded without identifiers.

Human Rights Protection
Human rights protection was a priority and was consistently monitored throughout the project. Initially, the project was presented to the University EPRC committee and facility IRB for approval. The human subjects' names and personal information were not included in any documentation. There was minimal risk to the subjects of this project. All human rights and ethical practices were reviewed with all stakeholders to ensure compliance and maintain privacy.

Formative/ Summative Evaluation
Evaluations are conducted on projects to assess the effectiveness and efficiency of project management and success (Nelson & Staggers, 2018). Formative evaluations were used in the project's implementation phase as feedback for continuous improvement and to identify whether changes were needed. Additionally, staff were involved in formative evaluations to assess the need for improvement, and to further ensure there were no gaps in communication. Meetings took place weekly during morning huddles. The team was able to address problems they had, and their suggestions to improve the project were considered. These meetings facilitated finding any weaknesses associated with the project and developing solutions to manage them. It was noted early on that the staff were having trouble getting patients to make their follow-up appointments, so a suggestion was made to send email reminders. When families received email reminders, the team noticed that they were more likely to call the clinic and make their appointments. (2018) suggested the use of summative evaluations to assess the outcomes and impact of a project. Summative evaluations were done within a week after the project was completed. The pre-and post-intervention data was collected, compared and evaluated to assess the discharge intervention bundle's effectiveness on 30-day hospital readmissions in medically complex children. Furthermore, summative evaluations revealed the intervention of implementing a discharge bundle considerably reduced the percentage of allcause, 30-day hospital readmissions in medically complex children.

Categories of Measures
Measurement, according to the IHI (2020), was critical in implementing change and leading improvement. The purpose of establishing measures was to bring new knowledge into current practice to further improve the facility's quality of healthcare. For this project, the independent variable was the implementation of a discharge intervention bundle. According to the IHI (2020) it was recommended that all evidence-based projects use a balanced set of measures for improvement that include; outcome measures, process measures, and balancing measures. Financial measures were also considered.

Outcome Measures
The IHI (2020) described outcome measures as the results of a process and their comparison with the intended results. This project's primary outcome was to reduce the 30-day all-cause hospital readmissions rate closer to the national average of 11% for CCC patients.
Readmission rates were ratio data and were collected at baseline and every 30 days throughout the project. This data was established pre-and post-project intervention through chart review audits of all clinic patients discharged from the hospital within the project's timeline. The student had access to the CCC shared drive that holds this information for the organization. Information on readmissions at surrounding hospitals was not obtained. The eight-week baseline pre intervention data showed a 24% readmission rate, while the post implementation eight-week data showed a 14.5% readmission rate. After analyzing the data there was a 10% difference from preand post-implementation data. This reduction in readmissions indicated an improvement in hospital readmissions using the evidence-based discharge bundle.
Secondary outcome measures included the percentage of patients who completed their post discharge outpatient or virtual follow-up appointments within seven days. Out of 41 discharged patients, 95% of them attended their follow-up within seven days. There were a few patients who did not show up to their scheduled appointments. The percentage of patients who received post discharge phone calls with education within 48-72 hours was 98%. The percentage of patients who received the teach-back method and medication reconciliation by the clinic nurses during the post discharge phone call was also 98%. Lastly, the percentage of patients whose charts were updated by the care coordinator prior to the post discharge follow-up was 100%. Data was shared with the team monthly throughout the project timeline.
I collected the readmission data by doing chart audits on discharged patients and filling out a check sheet. The ASQ (n.d.) suggested several valid and reliable tools for data collection and evaluation. One tool used was the check sheet, a structured form that could be adapted for a wide variety of data collection. It should be used when data can be observed and collected by the same person in the same location repeatedly and adapted for a wide variety of purposes (ASQ, n.d.). The document was a useful and reliable quality management tool widely used in healthcare to improve quality and care (Niñerola et al., 2020). The check sheet included the bundle interventions of post discharge phone calls, post discharge outpatient or virtual follow-up, education with teach-back, and medication reconciliation. The check sheet that was used for the project can be seen in Appendix E.

Process Measures
Process measures are the steps within the project that determine whether the project was performing as intended for practice improvement (IHI, 2020). Project process measures included the percent of the staff that received education on the discharge intervention bundle, and the percent of staff competent in the interventions using a pre-and post-evaluation tool. The process measure of the percentage of staff that received education on the discharge intervention bundle was determined by the total number of staff divided by the number of staff who signed in as having attended the training seminars. It was found that the percentage of staff that participated in the training was 100%.
The second process measure of the percent of staff competent in implementing the discharge bundle was measured by completing a conviction and confidence scale before and after the training seminar (IHI, 2019). The percentage of staff that showed confidence after training in being able to utilize teach-back within the bundle was 100%. A teach-back observation tool was also used for inter-rater reliability. Peers in the clinic were able to audit each other using the observation tool with patients.

Balancing Measures
Balancing measures often assessed whether improving one part of a system would cause new problems in other parts of the plan (IHI, 2020). The balancing measure for staff satisfaction with the new discharge bundle intervention was examined because it could affect staff satisfaction with their jobs. The project manager monitored staff satisfaction through individual conversations and observation and spoke to each team member weekly throughout the project's timeline to ensure staff satisfaction of the implementation process. Satisfaction was measured using a yes/no survey after the project was complete, and it showed 100% of staff reported satisfaction.
The balancing measure for patient satisfaction with the new discharge bundle was also examined as this intervention bundle affects their care. Family and patient satisfaction was measured using a yes/no survey given at their follow-up appointment and were deposited anonymously after patients were seen for their follow-up visits. They were instructed to place the survey in a patient survey box at the front of the office to be collected throughout the project. A response rate of 71% (29 of the 41 surveys were returned) reaped 100% satisfaction of the discharge intervention bundle.

Financial Measures
Financial measures were used to look at the projected direct and indirect costs associated with the project. This required creating a budget that was approved by the organization before implementation. Financial measures included the cost of training for the intervention bundle and indirect costs to the facility. The personnel involved in the project were RNs, a nurse practitioner, a care coordinator, a unit secretary and the CCC physician. The project did not exceed the cost projections. The estimated cost per medically complex pediatric readmission was $4,878 dollars for one day; $2,053 for ER visit with admission, and $2,825 for pediatric ICU stay (BayCare, n.d.-a). While this project did not include length of stay in its outcome measures, upon review it appeared the average length of stay was three days. The realized savings to the organization in the eight-week project timeframe was approximately $63,168. The projected savings over a one-year time frame was $379,008 for an average length of stay of three days.
The potential savings could be much greater if emergency room visits and length of stay are considered in the future of this evidence-based practice change.

Impact
This evidence-based practice change project's primary outcome was the reduction of allcause 30-day hospital readmissions in medically complex children. The project outcome was comparable to outcomes identified in the literature that demonstrated decreased hospital readmissions using discharge intervention bundles (Coller et al., 2018;Kamermayer et al., 2017;Stephens et al., 2017). The outcome of decreasing 30-day readmissions in medically complex children pre-and post-implementation data showed a decrease from 24% to 14.5%. While the sample size was not large, a decrease in overall readmissions was identified. Every prevented readmission was clinically meaningful as it decreased costs to the facility and reduced clinical, social and financial burdens for the patient and family (Coller et al., 2017). The evidence-based practice change project was implemented consistently as planned. Secondary outcome measures were the discharge bundle interventions of follow-up within seven days, phone calls within 48 to 72 hours, medication reconciliation with teach-back, and chart updates documented in the electronic medical record. These interventions were crucial to the project's success and the results from the process measures of patient and staff satisfaction were overwhelmingly positive for the discharge intervention bundle and vital to the organization's potential sustainability.
A limitation of the project was difficulty in contacting patients early on. Some patients did not answer phone calls, which made it difficult to schedule outpatient follow-up appointments. Once email reminders were sent out, families acknowledged the clinic's attempts and called for their follow-up appointments. Another limitation to the project included patients who did not show up to their follow-up appointments. Follow-up appointments were a key intervention within the bundle and helped ensure sufficient education and teach-back to the family to reduce readmissions. Lastly, the global COVID-19 pandemic limited the project's timeline and the potential to gain a more robust patient sample size and demonstrate the significance of the project's outcome.
Suggestions for the next steps are implanting this evidence-based practice change into new employee orientation for the clinic and into annual training programs for current staff. To ensure ongoing evaluation of effectiveness, hospital readmissions should be monitored monthly and analyzed at the end of each year. Implications for the future include a recommendation for further evidence-based research to determine any continuing education and interventions related to discharge intervention bundles to reduce 30-day readmission rates. The practice change project altered the process of discharges for medically complex children in the CCC. There is a continued opportunity to provide patients with improved transitions and quality of care. In all, to answer the PICOT, the takeaway from this evidence-based project is that the utilization of a discharge intervention bundle can reduce 30-day all-cause readmissions in medically complex children.

Plans for Dissemination
At the end of the project, an analysis of the results were completed before dissemination.
The AHRQ (2016) described the purpose of dissemination is to raise awareness, inform and educate the professional community, engage, get feedback from the community, and promote the results. A Microsoft PowerPoint presentation was created for the facility to share the project's findings. Key stakeholders including pediatric hospital leadership, clinical leadership, director of patient care, director of outpatient specialty clinics, medical director of children's hospital, quality, and risk management, CCC personnel, and the project team will be included in the original presentation. It is imperative to have key stakeholders present to obtain the buy-in of project success. This buy-in will promote project sustainability and implementation in other areas of the organization. The project manager is scheduled to disseminate the project findings at the case management, pediatric hospitalist and CCC staff meetings. Appropriate hospital leadership and key stakeholders have been invited.
With approval, local presentations will be accomplished through individual unit staff meetings while more extensive presentations can be given at grand rounds or town hall meetings.
Poster presentations can be used for local outreach to community practices with data to support the practice change. Additionally, poster presentations can be planned for local and national pediatric medicine conferences, such as the National Association for Pediatric Nurse Practitioners Conference. The publication of project findings will be another way to disseminate the results. Before submission of the publication, the proposal will need to be prepared according to journal specifications and be peer-reviewed. Submission to a journal that would best fit the project's setting, population and findings will increase the chance of acceptance. Therefore, the Journal of Pediatric Healthcare or the Complex Care Journal would be an ideal choice for publication due to its focus on evidence-based practices to improve patient care. Publishing in this journal would provide a wide range of dissemination to support the use of a discharge intervention bundle in medically complex children to reduce all-cause 30-day hospital readmissions. The final dissemination will be to upload the completed project to the institutional repository SOAR to publicly showcase the results of this evidence-based change project.

Conclusion
Children with medical complexity often have multiple medical problems which require specialists, equipment, and high acuity of care, leading to an increased rate of hospitalization and readmissions (Stephens et al., 2017). Literature supports the implementation of an evidencebased discharge intervention bundle to reduce readmission rates that includes post discharge telephone calls, post discharge outpatient follow-up, medication reconciliation, and education with the teach-back method (Coller et al., 2018;Kamermayer et al., 2017;Shermont et al., 2016;Stephens et al., 2017;Zhu et al., 2015). Implementing consistent discharge standards in medically complex children will guide medical staff, improve patient outcomes, save costs for the organization, and reduce 30-day all-cause hospital readmission rates.    After consent was obtained pts were randomized to one of four groups with interventions of usual care, and exercise program, nurse home visits and telephone follow-ups, or exercise and telephone followup. The control group received routine hospital and follow-up care by the health services.
The primary outcome was unplanned 28-day hospital readmission.
Data analysis was done using descriptive statistics for all variables. All data analyses were conducted based on intention to treat. Chi Square, ANPVA, and Kruskal-Wallis tests were used for bivariate analysis between groups.
In the 28 days following discharge the control group had a 25% readmission rate. The exercise group had a 14% readmission rate, nurse home visit and telephone follow-up had a 10% readmission rate, and the exercise and nurse home visit and telephone follow-up group had an 8% readmission rate. These results suggest that multifaceted transitional interventions can significantly reduce hospital readmission within 28-days.
Flippo, R., NeSmith, E., Stark, N., Joshua, T., & Hoehn, M. (2015). Reduction of 30-day preventable pediatric readmission rates with post discharge phone calls utilizing a patient-and family-centered care approach. Journal of Pediatric Health Care, 29 (6) The primary outcome is to improve medication adherence and lower readmission rates in patients with heart failure.
Data analysis was done using descriptive statistics, but the program used was not listed.
The results showed an increase in drug adherence in the intervention group. There was also a lower amount of 90day rehospitalization in the intervention group. The research concluded that the dual educational intervention with telephone follow-up in patients with heart failure is effective.
At what times during the day do you take this medicine? How much do you take each time?
If the patient answers in terms of how many pills, lozenges, suppositories, etc. What is the strength of the medicine? It should say a number and a unit such as mg or mcg.
How do you take this medicine? If there are special instructions (e.g., take with food), probe as to whether the patient knows the instructions and whether he or she is taking the medicine as instructed.
What do you take this medicine for?
Have you had any concerns or problems taking this medicine? Has anything gotten in the way of your being able to take it? Have you ever missed taking this medicine when you were supposed to? Why?
Do you think you are experiencing any side effects from the medicine?
If yes, could you please describe these side effects? Are you taking any other medicines? Repeat list of questions for each medicine.
After patient has described all medicines, ask: Are you taking any additional medicines that you haven't already told me about, including other prescription medicines, over-the-counter medicines, that is, medicines you can get without a prescription, or herbal medicines, vitamins, or supplements?
If patient has been prescribed medicines that the patient hasn't mentioned, ask whether he or she is taking that medicine.
If yes, go through the list of medicine questions.
If not, probe as to why not. If patient is unaware of the medicine, make a note to check with discharge physician as to whether patient is supposed to be taking it, whether a prescription was issued, etc.

CALLER:
Have you been using the medicine calendar (in your care plan) that was given to you when you left the hospital?
If yes, provide positive reinforcement of this tool. If no, suggest using this tool to help remember to take the medicines as directed. If patient has lost care plan offer to send a new copy of AHCP by mail or email.