Discharge Planning and Readmission: Change Model

The change proposal is focused on the nursing problem of discharge planning for patients aged 50 years and older and its impact on readmission rates. The potential solution is performing risk assessments before discharge to identify patients at risk for readmission and contact these patients within 48 hours after discharge (Gonçalves‐Bradley, Lannin, Clemson, Cameron, & Shepperd, 2016). Such an approach is considered a highly effective one by Kripalani, Theobald, Anctil, and Vasilevskis (2014). The nursing-focused plan comprises the change model overview, evidence of the issue, the implementation plan, and the conclusion. Also, the plan for assessing outcomes and reporting results is included.

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Change Model Overview

The change model to be used in the project is the ACE Star Model (“The ACE Star Model,” n.d.). The purpose of this change type is to provide a better understanding of the nature and components of knowledge that is employed in different aspects of evidence-based practice (EBP). The ACE Star Model helps to arrange old and current concepts of enhancing care and suggests a framework for the establishment of the most beneficial approaches and EBP processes (“The ACE Star Model,” n.d.). With the help of the ACE Star Model, it is possible to understand the connections between different phases of knowledge transformation when the newly found knowledge is applied in practice. Apart from that, the approach allows nurses to combine their previous scholarly work with current EBP.

The ACE Star Model involves five stages:

  1. “discovery research,”
  2. “evidence summary,”
  3. “transition to guidelines,”
  4. “practice integration,”
  5. “process, outcome evaluation” (“The ACE Star Model,” n.d., p. 1).

The transformation of knowledge includes such processes as the summarization, integration of suggestions, assessment of effects, and translation. Nurses should employ the ACE Star Model for change promotion because it contains all the constituents of the successful management of clinical issues.

Define the Scope of the EBP

The EBP issue is the readmission rate among patients aged 50 years and older. Particularly, discharge planning is the problem. The statistics indicate that in 2009-2010, the readmission rate in Veterans Affairs hospitals was as high as 15.2% (Kripalani et al., 2014).

In 2003-2004, the 30-day readmission rate among Medicare beneficiaries was 19.6% (Kripalani et al., 2014). The highest rates are usually reported for patients with chronic obstructive pulmonary disease, heart failure, recent vascular surgery, and psychoses (Kripalani et al., 2014). Since these conditions are prevalent in patients aged 50 years and older, it is crucial to find ways of reducing readmissions through changing approaches to discharge planning. The problem has a considerable impact on healthcare on a broader scale. Because of high readmission rates, excessive resources are used. This issue concerns both human resources (a higher nurse-patient ratio) and financial expenditures.


For each particular patient, a team will be formed to create the discharge plan. Apart from the team leader, the team will include the following members:

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  • the physician;
  • the charge nurse;
  • the patient;
  • the patient’s family (caregivers).

Determine Responsibility of Team Members

Each of the chosen members is important to the project because their combined efforts will lead to the creation of a successful discharge plan and the reduction of readmission rates. The role of the physician and the nurse is to perform the risk assessment of the patient and evaluate the possible problems with this customer. The patient must get acquainted with the discharge plan, adhere to it, and inform the team leader about any concerns. The function of family members or caregivers is to help the patient follow the plan, observe his or her condition, and inform the team leader about any difficulties. The role of the team leader is to arrange the work of each member and to contact the patient within 48 hours after discharge to ensure that the plan is working.


In addition to the evidence summary, EPB guidelines provided in the study by Wyer et al. (2016) will be used to discuss the strengths of the research. In their article, scholars argue that knowledge translation is a key component in the process of reducing readmission rates (Wyer et al., 2016). Another source offering evidence on the analyzed issue is the study by Boccuti and Casillas (2015). In their research, authors emphasize the need for more precise discharge instructions as a means of reducing readmission rates.

Summarize the Evidence

The systematic review article by Gonçalves‐Bradley et al. (2016) focuses on elderly patients and suggests the evaluation of personalized discharge plans for this population group. The most effective intervention offered by the authors is the elaboration of individualized discharge plans for patients leaving acute care units. In some of the analyzed cases, Gonçalves‐Bradley et al. (2016) incorporate post-discharge support in the intervention. This approach seems relevant and effective, and it will be used in the proposed change model.

Develop Recommendations for Change Based on Evidence

The suggestion grounded in research is to improve the pre-discharge knowledge transformation by providing patients and caregivers with relevant instructions concerning their post-discharge period. Another recommendation is to perform the risk assessment of these patients at a hospital and evaluate their condition within 48 hours after discharge.


Action Plan

The first step in implementing the project will be gathering EBP data and preparing the necessary educational materials for patients and caregivers. The next phase will comprise the development of the approaches to assessing the risk for readmission. Further, the risk evaluation will be performed, and the information will be provided to patients. The next step will be making post-discharge phone calls and finding out about the patients’ condition. Finally, the analysis and evaluation of the change project will be performed.

Process, Outcomes Evaluation, and Reporting

The desired results of the project are the improvement of patients’ health and the reduction of hospital readmission rates. The outcomes will be measured by comparing the statistics of readmissions 12 and 6 months before the program, at the beginning of the project, and 6 and 12 months after the intervention. The results will be reported to the key stakeholders in different ways. Patients will be informed via phone calls and emails. Healthcare workers will be reported at a team meeting.

Identify Next Steps

The plan can be implemented on a larger scale if it proves successful. The same or similar strategy may be employed in other units and hospitals. To ensure that the implementation becomes permanent, it will be necessary to perform a regular assessment of the intervention’s outcomes.

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Disseminate Findings

Internally, findings will be disseminated through a report and a staff meeting. Externally, findings will be shared through a leaflet containing the summary of the report.


The proposed change model is aimed at solving one of the most crucial problems of the healthcare system. Because of frequent readmissions, resources are used irrationally. Therefore, the creation of effective discharge plans is a practical approach to saving money, helping patients to recover faster, and making the workload of nurses lighter. The most important aspects of the ACE Star Model for maintaining the change plan are practice integration and outcome evaluation.


The ACE Star Model. (n.d.). Web.

Boccuti, K., & Casillas, G. (2015). Aiming for fewer hospital u-turns: The Medicare hospital readmission reduction program. Web.

Gonçalves‐Bradley, D. C., Lannin, N. A., Clemson, L. M., Cameron, I. D., & Shepperd, S. (2016). Discharge planning from the hospital (review). Web.

Kripalani, S., Theobald, C. N., Anctil, B., & Vasilevskis, E. E. (2014). Reducing hospital readmission rates: Current strategies and future directions. Annual Review of Medicine, 65, 471-485.

Wyer, P., Stojanovic, Z., Shaffer, J. A., Placencia, M., Klink, K., Fosina, M. J., … Graham, I. D. (2016). Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: A case study. Journal of Evaluation in Clinical Practice, 22(2), 171-179.

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