12 1 5-2 Project Preparation Royce Cleary Southern New Hampshire University IHP

12

1

5-2 Project Preparation

Royce Cleary

Southern New Hampshire University

IHP 604: Healthcare Quality Improvement

Dr. Patricia Thompson, DNP, RN

16 JUN 2024

Area Of Improvement

Memorial Satilla Health Hospital, located in Waycross, GA, recently reported to the CMS (Centers for Medicare and Medicaid Services) a successful return-to-home and community rate of 57.99%, which falls short of the national average of 66.93% (CMS, 2022). A successful return to home and community for an inpatient rehabilitation facility (IRF) is defined as a discharge without readmission within 31 days or expiration. The data utilized comes from the CMS Care Compare tool and a study by Middleton et al. (2018).

Method of Improvement

Upon reviewing the Memorial Satilla Health Hospital IRF rate, the proposed improvement method involves integrating two rehabilitative programs: a transitional living program and occupational therapy. These programs can provide individuals with a structured environment and improve a patient’s ability to perform daily tasks and activities independently.

Framework to use in Improvement Initiative

The implementation and assessment of these methods will follow the Plan-Do-Study-Act (PDSA) framework. Through PDSA, patients will be introduced to the new programs, and their progress will be recorded meticulously and compared against the national benchmarks and the study rates of Middleton et al. (2018). The level of data integrity will ensure the effectiveness of the proposed improvement initiative.

Selection Discussion

The improvement area was identified based on the Care Compare tool’s indication that Memorial Satilla Health IRF’s rate was below the national average. The study by Middleton et al. (2018), which demonstrated higher rates than the national benchmark, substantiates the need for an improvement initiative. The selected improvement methods are derived from current rehabilitative therapy recommendations, focusing on available programs suitable for all Memorial Satilla Health IRF patients. The PDSA framework was chosen for its dual prospective and retrospective capabilities, addressing the current substandard rate while establishing a forward-looking improvement strategy.

Report Selections

Middleton et al. (2018) conducted a retrospective cohort study examining successful return-to-home and community rates, incorporating variables such as demographic data, diagnosis, lengths of hospitals, and IRFs. In Figure 2, the study indicates a 63.7% success rate among 487,862 patients, slightly below the CMS national rate of 66.93% but significantly higher than Memorial Satilla Health’s rate of 57.99%. The relevant section of figure two for this improvement initiative highlights rates by IRF submitting claims to the Centers for Medicare & Medicaid Services during the study period.  The results of this study were performed at a 95% confidence interval. 

References

Medicare.gov. (n.d.). Find healthcare providers: Compare care near you. Medicare. https://www.medicare.gov/care-compare/details/inpatient-rehabilitation/11T003?city=Waycross&state=GA&zipcode=

Centers for Medicare and Medicaid Services. (n.d.). Inpatient rehabilitation facilities. CMS.gov. https://www.cms.gov/medicare/health-safety-standards/certification-compliance/inpatient-rehabilitation-facilities#:~:text=IRFsarefreestandingrehabilitation,intenserehabilitationservicesperday.

Middleton, A., Graham, J. E., Bettger, J. P., Haas, A., & Ottenbacher, K. J. (2018, November 2). Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries. Europe PMC. https://europepmc.org/article/MED/30646352