NURS4005 Assessment 4 Help

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Reducing Hospital Readmissions through Improved Transitional Care: An Interdisciplinary Approach to Enhance Patient Outcomes at Cleveland Clinic

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Organizational problem- High Readmission rates

The readmission rates are high among the patients with chronic conditions within 30 days (Yu et al., 2023) Breach of discharge planning (Yu et al., 2023) Poor patient awareness with regards to appropriate instructions. Expensive hospitalization costs

Why the Matter is Important.

Penalties in the Hospital Readmissions Reduction Program. Skewed patient satisfaction/level of trust in healthcare delivery (Yu et al., 2023). Negative effect on the quality rating of hospitals (Yu et al., 2023) Risks of death and negative consequences are high.

Interdisciplinary Approach to Team

Nurse and patient participation in the discharge and follow-up planning (Kongkar et al., 2025). Fungiella Inclusion of physicians in the discharge and follow-ups. The use of pharmacists in discharge and follow-up planning (Kongkar et al., 2025) Case manager role to the discharge and follow up planning.

The Reason Why an Interdisciplinary Approach?

Holistic/patient-centered care centers (Kongkar et al., 2025) Listens to opposing points to make informed choices. Safeguards against possible mistakes and ineffective communication. Ensures the provision of care every minute (Kongkar et al., 2025)

Overview of Interdisciplinary Plan

Discharge planning procedure Medication management system Self-care training of the patients concerning illnesses. Patient post-discharge monitoring

Plan of Implementation and Management of Resources.

staff interdisciplinary staff training on collaborative procedure (El-Sayed, 2023) How to enhance EHR systems (Jani, 2025) The funding of the technologies and human resources. Implementation plans evaluation and adjustment periodically.

Assessment and Performance Measures

Indicators: Aim to reduce hospital readmission rate by 15-20% in 30 days. Good patient survey on care obtained. Greater involvement and effectiveness of employees. Measure quality improvement technique

Expected Results and Conclusion

Safe secure patients and fewer complications. Less avoidable hospital admission (Jani, 2025) Proper use of resources and saving of cost. Better patient experience and care coordination

References

Bringsvor, H. B., Jørgensen, L., Åsgård, T., & Biringer, E. (2025). Employee readiness for change in a hospital building project. Procedia Computer Science, 256, 1640–1648. https://doi.org/10.1016/j.procs.2025.02.301 El-Sayed, N. (2023). Managing change in inpatient units using Lewin’s theory. Damanhour Scientific Nursing Journal, 1(1), 1–24. https://doi.org/10.21608/dsnj.2023.299981 Jani, P. (2025). AI-powered Predictive Analytics for Hospital Resource Allocation and Revenue Cycle Management. https://doi.org/10.56472/iccsaiml25-105 Kongkar, R., Ruksakulpiwat, S., Phianhasin, L., Benjasirisan, C., Niyomyart, A., Ahmed, B., Puwarawuttipanit, W., Chuenkongkaew, W., & Adams, J. (2025). The impact of interdisciplinary team-based care on the care and outcomes of chronically ill patients: A systematic review. Journal of Multidisciplinary Healthcare, 18(18), 445–457. https://doi.org/10.2147/jmdh.s497846 Yu, J. R. T., Sonneborn, C., Hogue, O., Ghosh, D., Brooks, A., Liao, J., Fernandez, H. H., Shaffer, S., Sperling, S. A., & Walter, B. L. (2023). Establishing a framework for quality of inpatient care for Parkinson’s disease: A study on inpatient medication administration. Parkinsonism & Related Disorders, 113, 105491. https://doi.org/10.1016/j.parkreldis.2023.105491