MHA FPX 5020 Assessment 3 Data Analysis and Evidence-Based Recommendations

Poor discharge planning and care coordination result in poor outcomes for the health care system, increased costs for the health care system, and greater-than-desired 30-day hospital readmission rates.

Factor #1 Examined

30-day hospital readmission rate

A precise number with a unit (days, dollars, %…)

Percentage (%) of patients readmitted within 30 days.

What kind of Graphic Data Summary (pie chart, bar graph, etc.)

Bar graph

The source of data will be provided in APA style.

Factor #2 Examined

Turnaround time of outpatient post-discharge.

Precise Unit of Measurement (days, dollars, %…)

The percentage (%) of patients who show up for the first follow-up visit (7-14 days after diagnosis) and the number of days taken for the first visit in the follow-up (first visit in the follow-up after diagnosis and the first follow-up).

Different Types of Graphic Data Summary (pie chart, bar graph, other)

Line graph.

Source of Data (APA Format)

Factor #3 Examined

Expression of gratitude in relation to care coordination for inter-hospital/inter-community practice.

Precise Unit of Measurement (days, dollars, %…)

Percentage of patients with recorded care coordination during a transition of care.

Type of Graphic Data Summary (pie chart, bar graph, other)

Pie chart

Source of Data (APA Format)

Factor 1 Graphic Observation or Insight

A. The 30-day readmission rate has increased significantly and conclusively from 2020 to 2025 to reflect poor discharge planning and care coordination as a growing concern in the healthcare industry. It is observable

B. The rising readmission rates imply that many patients are not receiving the readmission services they require. Patients are starting to have complications without these services and will be back in the hospital.”

C. Yet another component that has a dual impact on the high readmission risk and the transition-of-care plans under discussion is the lack of coordination of the care/discharge processes within a hospital.

D. Better discharge planning and faster provision of ancillary services will reduce readmission rates and improve patient outcomes.

Factor 2 Graphic Observation or Insight

A. The first group is those patients who are readmitted after discharge. The percentage of these patients is on the rise, and the carrying percentage reflects the likelihood of patients returning for follow-up care after discharge.

B. Although improved, the rates of never attending any of the follow-up visits remained high. This can cause complications and even result in patients being readmitted to the hospital.

C. Outpatient/within 7-14 days follow-up has an intricate relationship with a better outcome and less readmission; it is important in continuity care.

D. This means that there is a focus on practicals in healthcare systems, but interventions should be at higher levels so that patients adapt the same response post discharge.

Factor 3 Graphic Observation or Insight

A. Appropriate care coordination during transitions benefits the majority of patients, at 65%, but a considerable number of patients, at 35%, remain uncoordinated.

B. Poor coordination in the health care system increases the risk of adverse health outcomes for the population. These health outcomes include higher risks of readmission and health complications.

C. One may define good care coordination with respect to what it takes to achieve continuity of care, while patient safety may be seen to be reconciled with more productivity in contrast to what is achieved by continuity of care.

Therefore, in order to solve the problem, not the consequences, of the coordination process, it is necessary to address all of the avoidable readmission scenarios, all of the gaps in the coordination system, and also have an efficient transitional care program.

Recommendation:

Source

1. Make discharge planning routine. Offer patient education. Discharge instructions should be clear and concise. Accompany and assist patients who need physical support to complete the walk to their home from the hospital. This should lead to a decrease in 30-day readmissions.

Imhof, L., Heber, R., Blume, K. S., Schreyoegg, J., & Winter, V. (2025). Hospital Discharge Planning—An

2. Cross-disciplinary transitional care should be customized to improve the design of the hospital and/or community providers, and the result of care after discharge.

3. All patients may need to be guaranteed to receive the post-discharge outpatient visit, scheduled to be between 7 and 14 days following discharge, in order to assess their condition, check for any worsening, and prevent possible complications that may necessitate the need for re-hospitalization.

4. Standardize and execute multisectoral engagement and formal activities at the end of the care change process (transitioning care) and integration of Electronic Health Records (EHRs) to help minimize the information gap in the care change process;

Recommendation:

Rationale

1. An electronic system to monitor procedures that need to be performed before the discharge of patients should be installed.

This would ensure that all main discharge instructions, such as educating the patients, completing the medication reconciliation, scheduling follow-up appointments, and so on, would all be given in the same voice, reducing the chances of omissions and prompting readmissions.

2. In fact, come up with a patient post-discharge support hotline that will be effective 7 days after discharge.

This will empower the patients to prompt answers to their questions, establish regulations, issue commands, and eliminate the problems that would return them to the hospital.

3. Automated (by appointment/follow-up) follow-up (active) and adherence to medications, using SMS/mobile app

With increased reminders to patients, there is a greater potential for healthcare workers to realize the positive effects of increased patient adherence to treatment and follow-up visits. This results in increased continuity of care and a decrease in avoidable readmissions.