Patient, Family, or Population Health

Develop an intervention (your capstone project), as a solution to the patient, family, or population problem you've defined. Submit the proposed intervention to the faculty for review and approval. This solution needs to be implemented (shared) with your patient, family, or group. You are not to share your intervention with your patient, family, or group or move on to Assessment 5 before your faculty reviews/approves the solution you submit in Assessment 4. In a separate written deliverable, write a 5-7 page analysis of your intervention. Please submit both your solution/intervention and the 5-7 page analysis to complete Assessment 4. Introduction Introduction In your first three assessments, you applied new knowledge and insight gleaned from the literature, from organizational data, and from direct consultation with the patient, family, or group (and perhaps with subject matter and industry experts) to your assessment of the problem. You’ve examined the problem from the perspectives of leadership, collaboration, communication, change management, policy, quality of care, patient safety, costs to the system and individual, technology, care coordination, and community resources. Now it’s time to turn your attention to proposing an intervention (your capstone project), as a solution to the problem. Preparation Preparation In this assessment, you’ll develop an intervention as a solution to the health problem you’ve defined. To prepare for the assessment, think about an appropriate intervention, based on your work in the preceding assessments, that will produce tangible, measurable results for the patient, family, or group. In addition, you might consider using a root cause analysis to explore the underlying reasons for a problem and as the basis for developing and implementing an action plan to address the problem. Some appropriate interventions include the following: Creating an educational brochure. Producing an educational voice-over PowerPoint presentation or video focusing on your topic. Creating a teaching plan for your patient, family, or group. Recommending work process or workflow changes addressing your topic  

Sample Solution

  Problem Patient readmissions are a major problem in the healthcare system. In the United States, about 20% of patients are readmitted to the hospital within 30 days of discharge. This is a significant financial burden for the healthcare system, and it can also be a source of stress and anxiety for patients and their families.

Full Answer Section

  Causes There are many causes of patient readmissions. Some of the most common causes include:
  • Inadequate discharge planning. Patients who are not properly prepared for discharge are more likely to be readmitted to the hospital. This can happen if patients do not have a clear understanding of their medications, follow-up care, or how to manage their chronic conditions.
  • Complex medical conditions. Patients with complex medical conditions are more likely to be readmitted to the hospital. This is because these patients often need more intensive care and follow-up care.
  • Social factors. Social factors, such as poverty, lack of transportation, and inadequate housing, can also contribute to patient readmissions. These factors can make it difficult for patients to follow their discharge plans and to get the care they need.
Intervention The intervention that I propose is a patient-centered discharge planning program. This program would provide patients with comprehensive discharge planning services, including:
  • Education about their medications, follow-up care, and how to manage their chronic conditions
  • Assistance in making appointments with their healthcare providers
  • Help in obtaining transportation to and from appointments
  • Referrals to community resources, such as food banks and transportation services
The patient-centered discharge planning program would be implemented in a hospital setting. The program would be led by a team of nurses, social workers, and discharge planners. The team would work with patients to develop a personalized discharge plan that meets their individual needs. Evaluation The effectiveness of the patient-centered discharge planning program would be evaluated by tracking the number of patient readmissions. The program would be considered successful if it reduces the number of patient readmissions. Conclusion The patient-centered discharge planning program is a feasible and effective intervention to address the problem of patient readmissions. The program would provide patients with the information and resources they need to stay healthy after discharge. This would help to reduce the number of patient readmissions, which would save the healthcare system money and improve patient outcomes. Analysis The patient-centered discharge planning program is a comprehensive intervention that addresses the multiple factors that contribute to patient readmissions. The program would provide patients with the education, assistance, and resources they need to stay healthy after discharge. This would help to reduce the number of patient readmissions, which would save the healthcare system money and improve patient outcomes. The patient-centered discharge planning program would be implemented in a hospital setting. This would allow the program to reach a large number of patients who are at risk for readmission. The program would be led by a team of nurses, social workers, and discharge planners. This team would have the expertise and experience necessary to provide patients with the care they need. The effectiveness of the patient-centered discharge planning program would be evaluated by tracking the number of patient readmissions. The program would be considered successful if it reduces the number of patient readmissions. The patient-centered discharge planning program is a feasible and effective intervention to address the problem of patient readmissions. The program would provide patients with the information and resources they need to stay healthy after discharge. This would help to reduce the number of patient readmissions, which would save the healthcare system money and improve patient outcomes.

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