Posted: February 18th, 2023
Aims and Objectives: To identify structure, process, and outcomes associated with the implementation of transitional community-based management of hospital readmission rates.
Background: Population health-based projects have previously been described (Chapters 10 and 13). Using a transitional community-based readmissions plan for patients with heart failure, categorize quality metrics into structure, process, and outcomes.
Questions/comments to be considered are as follows:
Suggested response: The data input would be community health workers and patients with heart failure, the output would be readmission plans, and the measure of success would be surveying patient responses.
2, Explain how your devised model incorporates social context.
3.How will you assess your population or community?
Suggested response: The patient assessment instrument in Centers for Medicare & Medicaid Services (CMS) measure management programs can be used to assess the population or community.
SOLUTION
Based on the information provided, it appears that the study aims to identify the structure, process, and outcomes associated with the implementation of a transitional community-based management plan for hospital readmission rates among patients with heart failure.
Regarding the data input, community health workers and patients with heart failure would be the primary data sources for this study. It would be essential to collect data on the demographics, clinical characteristics, and readmission rates of patients with heart failure, as well as the structure and processes of the transitional community-based management plan. This data could be collected through medical records, patient surveys, and interviews with healthcare professionals and community health workers.
The outputs of the study would include the development and implementation of a transitional community-based management plan for patients with heart failure, as well as the documentation of its structure and processes. The outcomes of the study would include the assessment of the impact of the transitional community-based management plan on readmission rates and patient outcomes, such as quality of life, symptom management, and healthcare utilization.
Regarding the measures of success, it would be important to use a variety of quality metrics to evaluate the transitional community-based management plan. These metrics could be categorized into structure, process, and outcome measures, as suggested. Examples of structure measures could include the availability and accessibility of community health workers, the level of collaboration between healthcare providers and community health workers, and the adequacy of resources and training for community health workers. Process measures could
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