1. Readmission Rate of the ElderlyAfter StrokeJudith M. Shaffer RN, BSN Nurse Educator MSN Student Dr. LikenMSN 600

2. Introduction Rehospitalization rate of Elderly withstroke Purpose of Proposal Problem Statement Literature Review Summary References 3. Abstract Second leading cause of hospitaladmissions 30-day Readmission rate high Medicare costs Need for enhanced nursing care Theoretical framework used 4. Rehospitalization rates Serious issues for elderly with stroke Re-admissions costly Improved discharge planning Transitional care needed Program for the 30-daypost discharge 5. Background Indicator of quality and efficiency Causes of readmission Social support Nursing interventions needed Efficient framework to change currentpractices 6. Problem Statement Decrease the re-hospitalization rates Enhanced nursing care 7. Purpose Project RED Enhanced Nursing Support Decrease 30-day re-admission rate 8. SignificanceFour categories of nursing interventions Enhanced nursing care Improved patient education and support Multidisciplinary team management End of life care planProject RED 9. Project REDFacilitated by discharge advocateTelephone reinforcement providedPharmacist follow-upMain focus for transitional careDecrease readmission rate 10. Goals and AimsGoalsAims Develop a relevant Improved recovery ratenursing re-engineeredprogram Establish a defined post Decrease the re- stroke programadmission rates for theelderly with stroke Decrease in financial Increase in independence costsand safe return to ADLs 11. Significance of the Proposed ChangeClinical ImportanceBeneficiariesImproved Health Care Discharge PlanFinancial Effectiveness 12. Literature ReviewNo specific stroke related factorsPreventable health issuesBenefits stroke patientsLack of single interventionFurther research 13. Literature Review Summary and SynthesisEnhanced nursing careImproved patient transitionMultidisciplinary team managementEnd of life patient centered careUnknown Project RED success 14. Proposal Design and MethodStandard post stroke programChosen committeesNational OrganizationsFollow-up and SurveysProject RED sets guidelines 15. Theoretical/ Conceptual Framework Neuman Systems Model Physio- logical nursing client Line of defense Five variables logical Socio- ClientDevelop- mental systems Patient stabilityEnvironmentheath Optimal Wellness 16. Application of TheoreticalFramework30 patients from 3 hospitalsDischarge nurse advocateGrants appliedNursing personnelMultidisciplinary team 17. GuidelinesEstablished by Project REDResponsibilities Patient teaching Availability Coordinates care Social network support Maintain updated changes 18. EvaluationQuestionnaires Patients Multidisciplinary TeamPersonal interviewsFocus GroupsHome care visits 19. Professional Role of the APNBuilt on competence as RNNurse Advocate Assesses Plans and organizes Implements program Coordinates team Evaluates 20. Conclusion Reduce readmission rates for elderlywith stroke Initiate transitional program Nurse advocate 21. Questions 22. References References available upon request Template provided by Animation Factoryretrieved fromhttp://www.animationfactory.com judithshaffer @student.kaplan.edu 23. Special thanks to Denise Holmes MSN, RNClinical Instructor at ECPI University Thank you Dr. Liken, Dr. Adelman, Dr. Treschuk& all my professors,Fellow classmates,And above all,To my family for IN MEMORY OF MYtheir patience and support asDAD I traveled this journey.