The provision of continuous health care suggests the optimization of the units’ functions. The decrease of preventable readmissions and unnecessary hospitalizations refer to the optimizing strategies. On the way, the skilled nursing facilities (SNF) are the units where the quality of care and prevention of numerous transitions appear to be the challenging chains in the system advances. The growing group of the older patients with chronic diseases, and diabetes in particular, in these facilities creates additional pressure. The paper aims at discovering the significance of quality care in SNF as a preventable factor for acute readmissions of diabetic patients.
Preparing for the role of a nurse practitioner, I am working as a nurse case manager that contributes to the development of the professional potential in solving the emerging problems of efficient health care management. The care delivery to diabetic patients concerns the crucial domain of my advanced practice in the SNF clinical setting. The experience shows the coordination and provision of fluent transitions between the care episodes require an increased attention. The diabetic patients in the facility often feel confused while obtaining only the fragments of specialized medical and psychological care. In turn, nurse professionals are limited with the technical, time, and financial resources to integrate the chain of services. Hence, enhancing the quality of similar clinical settings and, as a result, improving the patient’s well-being refer to the critical issues of nursing to be investigated (AACN, 2016). The SNF functioning is detected to be controversial while is known for high readmission rate (Neumann, Wirtalla, Werner, 2014). In the light of the problem, my specialisation can serve the most appropriate field to become the change agent to translate the quality innovations into the team and patients’ collaboration.
To discover the significance of the changes, the search for the academically recognized studies in the field is fulfilled. The search in South Online Library suggests distinguishing the original research articles from peer-reviewed health care journals including qualitative and quantitative nursing studies in SNFs. To pick out the problem constraints, the terms “diabetes care”, skilled nursing facility”, and “acute readmissions” were used in the search engine. In the result of the literature exploration, longitudinal evaluation studies and randomized clinical trial were selected. The literature points to the statistically significant relations between the quality of care in SNF and the acute readmissions and the role of the advance nursing staff in improving the performance.
The identified literature confesses the increased attention of national health care policy to the quality improvements in SNFs as the post-acute settings directed to minimize costly and complicated readmissions. In the same time, these facilities are distinguished to be the ones with the most apparent gaps in the care delivery systems (Meehan et al., 2015). Moreover, the frequent readmissions are more likely to be related to chronic diseases’ exacerbations in older patients. The study by Neumann et al. (2014) discovers the diabetes comorbidities that complicate post-acute rehabilitation to be among the leading reasons of readmissions. Nevertheless, another research by Ouslander et al. (2016) shows that 23% of unnecessary hospitalizations can be prevented. The solution of the problem lies within the domain of quality care advances.
Consequently, the innovative tools for the decreasing the acute readmissions after SNF discharge should provide the intelligent technical and management systems for transitional and post-care process. The quality improvement (QI) national program offers opportunities to facilitate the changes that are argued to be efficient (Meehan et al., 2015;). The Interventions to Reduce Acute Care Transfers (INTERACT) option and information technologies for care coordination suggest the perspective resources guiding the QI intervention (Ouslander et al., 2016; Samal, Dykes, Greenberg, Hasan, Venkatesh, Volk, & Bates, 2016). These tools enable to distinguish the needs and the components for the staff and patients training as well.
Altogether, the identified gaps in the health care delivery imply the problem of readmissions and unnecessary transitions that are costly, complicated, and lead to higher mortality in older patients with chronic conditions. The SNFs refer to the most vulnerable settings, still the most perspective for the NP to initiate the quality changes reducing acute readmissions. The QI programs and tools together with the informational technologies for care coordination may serve the innovative platform to recognize and eliminate the factors triggering the health care system errors.
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