Full Answer Section

Objective and Predictions:

The objective of this plan is to reduce hospital readmissions for HF patients by 10% within one year through the implementation of a comprehensive discharge education and follow-up program. This program will be delivered by an interdisciplinary team consisting of cardiologists, nurses, pharmacists, social workers, and dieticians.

We predict that by providing patients with a more holistic discharge plan that addresses medication adherence, dietary management, symptom recognition, and social support needs, we can significantly reduce readmissions. Studies have shown that comprehensive discharge education programs can decrease readmission rates by up to 20% ([Naylor et al., 2004]).

Change Theory and Leadership Strategy:

This plan utilizes the Transtheoretical Model (TTM) of behavior change ([Prochaska & DiClemente, 1983]). The TTM posits that individuals progress through stages of change (precontemplation, contemplation, preparation, action, maintenance) when adopting new behaviors. Our program will cater to patients at various stages by providing educational materials, motivational interviewing techniques, and relapse prevention strategies.

Leadership will be crucial for successful team collaboration and plan implementation. We propose a shared leadership approach where team members contribute their expertise and participate in decision-making ([Mumby et al., 2007]). A cardiologist will act as the team leader, providing overall direction and facilitating communication. The team will hold regular meetings to discuss patient progress and adjust the program as needed.

Interdisciplinary Collaboration:

Effective collaboration is essential for this program’s success. The team will utilize the following best practices:

• Shared Goals and Vision: All team members will be informed about the high readmission rate and the program’s goals.
• Mutual Respect: Each team member’s expertise and experience will be valued.
• Open Communication: Regular meetings, clear communication channels, and active listening will be fostered.
• Shared Roles and Responsibilities: Each team member will have clearly defined roles within the program.
• Conflict Resolution Strategies: A process for addressing disagreements constructively will be established.

Organizational Resources:

The following resources will be required:

• Personnel: Time commitment from cardiologists, nurses, pharmacists, social workers, and dieticians for patient education and follow-up.
• Technology: Development of educational materials and an electronic platform for patient communication.
• Funding: Budget allocation for printing educational materials and potential software subscriptions.

Impact on Resources:

Reduced Readmissions: A successful program can significantly reduce hospital readmission rates. This translates to cost savings for the hospital and improved resource allocation.

Improved Patient Outcomes: Reduced readmissions lead to better patient outcomes, improved quality of life, and potentially lower long-term healthcare costs.

Enhanced Staff Collaboration: A successful program can foster a culture of collaboration among various departments, leading to improved communication and overall patient care.

Conclusion:

This interdisciplinary collaborative plan offers a data-driven approach to address the issue of high readmission rates for HF patients at Mercy Hospital. By implementing a comprehensive discharge education and follow-up program, utilizing the TTM and shared leadership, and fostering effective collaboration, we predict a significant reduction in readmissions, improved patient outcomes, and cost savings for the organization.