Date of Completion

Summer 7-17-2024

Document Type

Open Access Project

Degree Name

Doctor of Nursing Practice (DNP)

Faculty Advisor

Dr. Joanne Roman Jones

Site Advisor

Dr. Ryan Thompson

Second Reader

Dr. Ellen Benjamin; Dr. Lisa Ann Heard

Abstract

Abstract

BACKGROUND: Care transition plans, locally called Acute Care Plans (ACPs), are created specifically for super utilizers of the Complex Care Medicine Service (CCMS) and are a target for improvement. The purpose of this project was to improve care for CCMS patients by developing, implementing, and evaluating a standardized CCMS ACP. A multidisciplinary approach was chosen to facilitate the transitions of care process during an admission or discharge from the hospital.

LOCAL PROBLEM: The purpose of the ACP is to get a quick summary of how to treat a patient when they come to the hospital. The ACPs are unstructured, content is greatly variable, and updates lack ownership.

METHODS: The intervention for this quality improvement initiative includes the following: to standardize the ACP for CCMS patients; to educate CCMS providers on transitions of care and what to include in the standardized ACP; huddles with the Emergency Department (ED) providers to evaluate the implementation process; and huddles with CCMS providers to identify barriers and successes evident from the ACP improvement process. The intervention was evaluated after twelve weeks by comparing the number of CCMS patients that have a standardized ACP in place at the time of discharge compared to the start of the Quality Improvement project.

RESULTS: The results of the standardization of the CCMS ACPs were favorable. At the start of this QI project there were 40 CCMS patients that had an ACP in the EMR. At the completion of this QI project there were 65 CCMS patients that have a standardized ACP in the EMR. This project demonstrated that by standardizing the ACPs, the care of the CCMS patients improved.

CONCLUSIONS: This project demonstrated that by standardizing the ACPs, providers perceived that their care of CCMS patients improved. At the close of the project, all ACPs at issue had a standardized plan of care.

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