The following is a brief introduction to the topic:
This plan implements the assessment 1 initiative, which aims to improve the healthcare services and outcomes of elderly patients suffering from chronic illnesses by setting up a program for transitional care. By providing coordinated services for care and by reducing avoidable hospital readmissions, the proposed initiative will address current challenges and inefficiencies within the healthcare system. This initiative requires financial support and staff, organizational restructuring and community collaboration. The implementation plan includes a description of the proposal, as well as a budget, timeline and organizational analysis.
This initiative is an effort to provide a program of transitional care that will improve the health and healthcare outcomes for older patients who have chronic illnesses. Patients who transition from hospital to home, or to another care setting will receive coordinated care through the transitional care program. A team of health care professionals will be involved in the transitional care program, which will include nurses, social workers and care coordinators. They will all work together so that patients get timely and appropriate care.
Transitional Care Program Components
- The screening and identification process of patients who qualify for the program: Patients that are eligible will be identified via a risk assessment for readmission to hospital. Patients must be 65 years old or older with one or more chronic diseases and at risk for readmissions to hospital.
- Comprehensive assessment and planning of care: Patients that are eligible to participate in the Transitional Care Program will receive a thorough assessment, which will review their medical histories, list of medications and other health-related information. Based on the assessment, a care plan will be developed that will identify the patient’s care needs, goals, and preferences.
- Care coordination and Management: A team of health professionals will implement the care plan, providing coordinated services for patients. The coordination team works together to provide timely and appropriate care for patients. This includes medication management, monitoring symptoms, and scheduling follow-up appointments.
- Education and Self-Management: Patient will receive support and education to assist them in managing their chronic diseases and preventing hospital readmissions. The information provided to the patients will include medication management techniques, self-care methods, and recognition of symptoms.
To cover capital and staffing costs, as well as material and personnel expenses, financial resources are required. In Table 1, the estimated budget of the project for its first five years is shown.
Table 1 Table 1
|The Item||Costs (Year 1)||Costs (Year 2)||Cost for Year 3||Cost for Year 4||Cost for Year 5|
|Personnel (nurses and social workers as well as primary care doctors, coordinators of care, and care coordinators)||$400,000||$450,000||$500,000||$550,000||$600,000|
|Costs of materials (office supplies, equipment and patient education materials).||$50,000||$55,000||$60,000||$65,000||$70,000|
|Capital cost (IT hardware, software and systems)||$100,000||$150,000||$200,000||$250,000||$300,000|
This initiative should generate revenue from reducing avoidable hospital readmissions, and by improving the health of patients. Table 2 shows the projected earnings of the initial five years.