DNRS 6211 Week 9 Business Case Example

Business Case: A Nurse-Led Transitional Care Clinic for Stroke Survivors at Highest Risk of Readmission After Inpatient Rehabilitation

Student Name

College of Nursing, Walden University

DNRS 6211: Finance and Economics in Healthcare Delivery

Instructor Name

Month Day, Year

Business Case: A Nurse-Led Transitional Care Clinic for Stroke Survivors at Highest Risk of Readmission After Inpatient Rehabilitation

Problem

Each year the composite 18-bed inpatient rehabilitation unit discharges about 197 stroke survivors to home. The unit's quality report shows that 118 of them have at least two chronic conditions besides stroke, such as heart failure, diabetes, or chronic kidney disease, and that this group's 30-day readmission rate is 18%, about 21 readmissions a year, compared with 7% for the others. Most of these patients see their primary care clinician 2 to 4 weeks after discharge, according to the scheduling record, and the first week at home is when medication problems, falls, and swallowing difficulties tend to surface. The unit already calls every patient discharged home at 48 hours and 7 days, but a call cannot examine a patient, adjust a medicine, or check a swallow. A study of Medicaid discharges found that follow-up within 7 days was associated with meaningful reductions in readmission for patients with multiple chronic conditions and high baseline risk, while most lower-risk patients gained little from early follow-up (Jackson et al., 2015). The unit's high-risk stroke group fits that description.

Options

Option A: continue as things stand. The unit keeps its follow-up calls and patients see their own clinicians when appointments allow. There is no new cost. Readmissions in the high-risk group are expected to stay near 21 a year, each costing the hospital about $14,000 when the patient is in a risk-bearing contract. The option carries no implementation risk, but it also offers no route to improving the unit's results under the stroke bundled payment the hospital joined this year.

Option B: add a nurse practitioner phone review. A nurse practitioner reviews each high-risk patient by phone within 7 days, using the call nurse's findings, and can adjust medicines by phone. The cost is about $15,000 a year in nurse practitioner time. It improves on calls alone, but the patient is never examined, and because transitional care management billing requires a face-to-face visit, the review produces no revenue to offset its cost.

Option C: open a nurse-led transitional care clinic. High-risk patients are seen in person within 7 days of discharge by a registered nurse, with a nurse practitioner for the medical portion of the visit. The visit covers medication reconciliation, blood pressure, swallowing and nutrition, mood, falls, and caregiver teaching. The recurring cost is $91,690 a year, partly offset by transitional care management billing. It is the only option that examines the patient in the first week, and it draws on a model of nurse-led transitional care that reduced readmissions in a randomized trial of older adults (Naylor et al., 1999).

Recommendation

The unit recommends Option C. It is the only option that can find and fix problems that a phone call cannot, in the patients whose risk makes early follow-up worth its cost. The cost of being wrong is stated plainly: if the clinic reduces readmissions by nothing, the hospital spends about $69,000 a year, net of billing, for a service that did not work. The measures and review date in the implementation section are set so that this would be found within 6 months, not after several years.

Option B is the strongest rejected option. It costs less, but it cannot examine a swallow, check an orthostatic blood pressure, or watch a caregiver draw up a medicine, and those are the problems most likely to send a stroke survivor back in the first week.

Financial Summary

The workings are in Appendix A (costs) and Appendix B (benefits and billing). In summary, the recurring cost is $91,690 a year: a 0.5 FTE registered nurse at $60,840 including benefits, a 0.15 FTE nurse practitioner at $25,350, clinic space from the outpatient rehabilitation department at an internal charge of $4,000, and $1,500 in supplies. A one-time setup cost of $3,500 covers scheduling and record templates. The financial return has three parts. A 25% reduction in readmissions in the high-risk group avoids about 5.3 readmissions a year; with 60% of patients in risk-bearing contracts, that is worth $44,604. Transitional care management billing for about 100 visits at an average of $230 brings $23,000. Fewer emergency visits add $2,336. The total is $69,940, for a net cost of $25,250 in the first year and $21,750 in later years. If risk-bearing contracts cover 75% of these patients next year, as the finance office projects, the net cost falls to about $10,000 (Reiter & Song, 2021).

Risks

Table 1 lists the main risks, each with a mitigation and an owner.

Table 1

Risks, Mitigations, and Owners for the Transitional Care Clinic

Implementation and Measures

The measures come first, so that the timeline serves them. Primary: 30-day readmission rate in the high-risk group, against the baseline of 18%. Secondary: share of eligible patients seen within 7 days (target 85%), emergency visits within 30 days, and transitional care claims paid. The milestones are space and templates ready by month 1, first patients seen in month 2, the first review of all measures at month 6, and a decision to continue, narrow, or stop at month 12.

Decision Requested

The unit asks the hospital's operations committee, at its next meeting, to approve Option C for a 12-month trial and to release $95,190 from the nursing division's operating budget for the first year: $91,690 recurring and $3,500 one-time. The committee is also asked to agree now that the month 6 review will be reported to it, with the readmission result, so that a decision to stop can be made early if the clinic is not working.

References

Jackson, C., Shahsahebi, M., Wedlake, T., & DuBard, C. A. (2015). Timeliness of outpatient follow-up: An evidence-based approach for planning after hospital discharge. Annals of Family Medicine, 13(2), 115-122. https://doi.org/10.1370/afm.1753

Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA, 281(7), 613-620. https://doi.org/10.1001/jama.281.7.613

Reiter, K. L., & Song, P. H. (2021). Gapenski's healthcare finance: An introduction to accounting and financial management (7th ed.). Health Administration Press.