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An interdisciplinary team includes many healthcare professionals working together and utilizing their skills, knowledge, and expertise to provide holistic and quality patient care.
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An interdisciplinary team includes many healthcare professionals working together and utilizing their skills, knowledge, and expertise to provide holistic and quality patient care. Here are a few more healthcare professionals.
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Managing cardiomyopathy involves addressing underlying or precipitating causes, treating heart failure with medications, and implementing dietary changes and a balanced exercise and rest regimen.Lifestyle ModificationsCardiomyopathy patients should adopt a low-sodium diet to reduce fluid retention and manage heart failure. A personalized exercise and rest plan helps maintain physical fitness without overstraining the heart. Avoiding alcohol and tobacco is essential to prevent further damage to...
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Aneurysm management involves either conservative medical therapy or surgical intervention, depending on the size and symptoms of the aneurysm. Conservative management is generally reserved for smaller, asymptomatic aneurysms, while larger or symptomatic aneurysms often necessitate surgical repair.Conservative Medical TherapyFor small, asymptomatic aneurysms, particularly abdominal aortic aneurysms (AAA) less than 5.5 centimeters in diameter, conservative medical therapy is recommended. This...
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Venous thrombosis requires effective prevention and treatment strategies to improve patient outcomes and reduce potential complications.Prevention StrategiesHealthcare providers must prioritize preventing venous thromboembolism (VTE) for all adult patients upon admission. Interventions depend on bleeding and thrombosis risk, medical history, current medications, diagnoses, planned procedures, and patient preferences. Patients on bed rest should change positions every two hours and, if not...
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Interprofessional care for coronary artery disease includes pharmacological therapy and revascularization procedures.Pharmacological therapy for Coronary Artery Disease (CAD) aims to manage symptoms, prevent complications, and improve patient outcomes through various classes of medications:Antiplatelet Agents:Aspirin and Clopidogrel: These medications inhibit platelet aggregation, preventing blood clots, which is crucial for avoiding heart attacks and strokes. Doctors often prescribe these...
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Implementing Posthospital Interprofessional Care Team Visits to Improve Care Transitions and Decrease Hospital

Stacy M Baldwin1, Sharon Zook, Julie Sanford

  • 1Stacy M. Baldwin, DNP, FNP-BC, is the Doctor of Nursing Practice for Charter Health Care Group in Rancho Cucamonga, California. She received her DNP from James Madison University and her Bachelor's and Master's degrees specializing as a family nurse practitioner from the Virginia Commonwealth University School of Nursing. She has over 10 years of experience in management of chronic disease populations and in implementing transitional care models for high-risk patients. As a Lean Six-Sigma Greenbelt, she has vast experience in clinical innovation and has presented her work at local, state, and national health care conferences. Sharon Zook, DNP, FNP-BC, is a professor in the School of Nursing and Graduate School at James Madison University. She has over 30 years of teaching experience, with 12 at the graduate level. She has participated in funded research and has presented and published on teaching pedagogies, international education and chronic illness management. Her clinical expertise is chronic illness self-care and management. She is licensed as a Master Trainer for the Chronic Disease Self-Management and Diabetes Self-Management Program out of Stanford University. Dr Zook has conducted numerous client and leader trainings. Julie Sanford, DNS, RN, FAAN, is a professor and Director of the School of Nursing at James Madison University. She has published and presented in the areas of interprofessional education and collaborative practice, health policy, informal caregiving, and the scholarship of teaching and learning. She has taught at all levels of nursing education and obtained HRSA funding to lead development of one of the first BSN to DNP adult gerontological acute care NP programs in the country. She became a fellow in the American Academy of Nursing in 2017 and has served as the Director at JMU since 2011. She is a graduate of the University of Alabama, University of South Alabama and LSU Health Science Center.

Professional Case Management
|July 31, 2018
PubMed
Summary
This summary is machine-generated.

An interprofessional Discharge Clinic significantly reduced 30-day hospital readmissions for complex patients, achieving a 2.7% rate compared to national benchmarks. This innovative model offers substantial cost savings and improved care transitions.

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Area of Science:

  • Healthcare Management
  • Patient Care Coordination
  • Health Services Research

Background:

  • Increasingly complex patient populations with multiple comorbidities necessitate improved acute and primary care integration.
  • Transitions of care from hospital to home are critical for patient safety and reducing healthcare costs.
  • Existing care models often struggle to bridge the gap between acute hospital settings and primary care.

Purpose of the Study:

  • To evaluate the effectiveness of an interprofessional posthospital follow-up clinic (Discharge Clinic) in improving transitions of care.
  • To decrease 30-day hospital readmission rates for patients with complex care needs.
  • To assess the impact of an interprofessional care team on post-discharge outcomes.

Main Methods:

  • Implementation of an innovative, interprofessional Discharge Clinic.
  • The care team comprised a certified family nurse practitioner, clinical pharmacist, nurse case manager, and social worker.
  • Focus on patients discharged from an acute care setting requiring complex care management.

Main Results:

  • Achieved a 30-day readmission rate of 2.7% for 75 enrolled patients (February-September 2016).
  • This rate is significantly lower than national benchmark data (17.3% for Medicare, 8.6% for private coverage in 2013).
  • Estimated net savings of $335,199.84, with a 9.63% reduction in readmissions and an estimated cost savings of $689,199.84.

Conclusions:

  • The interprofessional Discharge Clinic model effectively improves transitions of care for complex patients.
  • This approach significantly reduces 30-day hospital readmissions and generates substantial cost savings.
  • The model is replicable by health systems nationwide to enhance patient management across acute and ambulatory settings.