Advanced Health Assessment for Patients and Populations

Advanced Health Assessment for Patients and Populations

Healthcare facilities and professionals are dedicated to promoting and ensuring quality patient outcomes and safety. Some health conditions are prone to relapse, and healthcare providers strive to prevent relapse. Interventions such as the HRRP program have been introduced to help improve care quality and monitoring to prevent relapse and other health problems. This essay evaluates a case study and discusses evidence-based interventions to prevent readmission within thirty days of discharge for the patient and all-cause hospital readmission.

The HRRP Readmission Plan and Case Study

The HRRP program is a valued-based system that aims to reduce readmissions for patients with the following conditions: acute myocardial infarction, chronic obstructive pulmonary disease, heart failure pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty/ total knee arthroplasty (Center for Medicare and Medicaid, n.d.). The Center for Medicaid and Medicare deducts up to three percent of reimbursements for hospitals with high patient readmission rates.

The CMS compares hospitals’ performance to others with similar patient proportions and deducts payments based on the number of excess readmissions within thirty days post-discharge (Center for Medicare and Medicaid, n.d.). The payments are deducted for the conditions listed above only. However, hospitals can dispute deductions by the CMS within a thirty-day window if they feel the deductions were unfair.

This paper focuses on Reggie, a 72-year-old African American male with Heart Failure. The focus is to reduce hospital readmission after his discharge from the facility. Reggie had developed complications such as swollen legs, a distended abdomen, and shortness of breath. Interventions during the stay were Lasix, potassium supplements, other medications, low sodium diets, and fluid restriction.

Prevention of disease relapse is significant for quality patient outcomes and meets the requirements of the HRRP program. Patient follow-up with cardiologists or the primary care provider seven days post-discharge is vital. The focus is to enhance patient outcomes and prevent complications that could lead to readmission within 30 days post-discharge.

All-Cause Hospital Readmission Prevention

Social determinants of health that can affect readmission include access to healthcare, knowledge of health interventions, income level, neighborhood, and education level (Evans et al., 2021). These determinants of health can be addressed using various evidence-based interventions that aim to reduce all-cause hospital readmission. These interventions to reduce hospital readmission for all-cause conditions include a comprehensive discharge plan (Nair et al., 2020).

The plan entails comprehensive patient education on the condition, complications, symptoms, management interventions and adherence. The plan also entails a comprehensive assessment to determine if the patient meets the discharge criteria for that condition (such as fair general state, no current symptoms, initial symptoms have resolved or stabilized, and vitals are within normal ranges). Other interventions include a well-stated return date and discharge medications or related medical interventions.

Another intervention is patient follow-up at home or in the home. Follow-up entails a comprehensive review of patient progress and managing any deviations accordingly. Nair et al. (2021) note that a weekly or biweekly follow-up with the patients is integral for patient prognosis and management, preventing relapse and subsequent readmission. The intervention helps determine patient prognosis, determine deviations early and address them adequately to prevent complications.

Other institutions have implemented complex/comprehensive interventions such as the home healthcare program. Patients with chronic conditions, the elderly, and those at high risk for readmission are enrolled in these programs. The patients are monitored daily by nurses and physicians in their homes, and current needs are addressed. The programs effectively promote care transition from the facility to the homes.

According to Vernon et al. (2019), the program reduces hospital readmission significantly, promotes quality outcomes, eliminates complications, and increases access to timely care interventions. Vernon et al. (2019) also note that home healthcare programs are improved forms of follow-up services that allow nurses and other healthcare providers to continue providing healthcare services and other support interventions to patients in their homes.

Primary, Secondary, And Tertiary Strategies to Prevent Reggie’s Readmission

Reggie will require comprehensive education at discharge to continue treatment at home (Nair et al., 2020). The education at discharge entails information on the condition, complications assessment, medication, and non-medical interventions such as a low-sodium diet (Ryan et al., 2019). Family education is integral to ensuring adequate support throughout his care.

The patient should be adept to self-care, and the education will equip him with adequate knowledge to recognize early signs of complications and promptly report them to help address them and prevent readmission (Nair et al., 2020). According to Ryan et al. (2019), an early 7-day follow-up with the cardiologist is significant for heart failure patients. The follow-up helps detect exacerbations and complications early. Reggie’s clinic appointment with the cardiologist is a week post-discharge.

Medication reconciliation for Reggie is significant for quality outcomes. According to Ryan et al. (2019), nurses and other healthcare providers should review the current plan thoroughly to ensure it meets the patients’ needs and revisit it accordingly. The cardiologists and care provider should review his current medications to prevent future exacerbations. In addition, considering medication optimization will positively impact patient health outcomes. In addition, diuretic medication dosages should be curated based on his needs and ability to regulate blood pressure.


Hospital readmission within 30 days after discharge could indicate poor care quality and patient safety. Reggie, a heart failure patient, needs a comprehensive care plan to prevent readmission thirty days after discharge. Interventions such as patient education, home health, and follow-up help reduce readmission significantly. For Reggie (the 72-year-old heart failure patient), medication reconciliation, reassessment of the current plan, comprehensive discharge education, and a 7-day follow-up will help reduce his readmission and ensure quality health outcomes.


Center for Medicare and Medicaid (n.d.). Medicare-Fee-for-Service-Payment/Acute Inpatient PPS: Hospital Readmissions Reduction Program (HRRP). Accessed July 27, 2023, from

Evans, W. N., Kroeger, S., Munnich, E. L., Ortuzar, G., & Wagner, K. L. (2021). Reducing readmissions by addressing the social determinants of health. American Journal of Health Economics7(1), 1-40.

Nair, R., Lak, H., Hasan, S., Gunasekaran, D., Babar, A., & Gopalakrishna, K. V. (2020). Reducing all-cause 30-day hospital readmissions for patients presenting with acute heart failure exacerbations: a quality improvement initiative. Cureus12(3).

Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence-based processes to prevent readmissions: more is better, a ten-site observational study. BMC Health Services Research21, 1-11.

Ryan, C. J., Bierle, R., & Vuckovic, K. M. (2019). The three Rs for preventing heart failure readmission: review, reassess, and reeducate. Critical Care Nurse39(2), 85-93.

Vernon, D., Brown, J. E., Griffiths, E., Nevill, A. M., & Pinkney, M. (2019). Reducing readmission rates through a discharge follow-up service. Future Healthcare Journal6(2), 114.

Advanced Health Assessment for Patients and Populations Instructions

  • Research the CMS HRRP
  • Briefly discuss the elements and criteria used for the CMS HRRP conditions/procedures payment reduction plan for readmissions within 30 days of discharge.
  • Develop/propose a Care Transition Plan for the patient with the condition chosen ( see Scenario below)
  • Incorporate individual, social determinants, community, system-level, and condition/procedure specific considerations with emphasis on interventions and initiatives to prevent readmission within 30 days of discharge.
  • Research the evidence-based practices for effectively transitioning patients from the hospital (& rehabilitation unit) to home with the specific focus on preventing all-cause hospital readmission. Utilize your textbooks, online resources, and other sources as needed.
  • Discuss evidence-based practices focused on preventing all-cause hospital readmissions.
  • Incorporate individual, community, system, and social determinants of health considerations that impact all-cause readmission and how to prevent them.
  • Based on research, create an extension of the HRRP that focuses on successfully preventing hospitalization through primary, secondary, and tertiary prevention methods.

Initiatives should incorporate individual, social, community, system-level, and condition/procedure specific considerations.



Reggie is a 72-year-old black male who is being discharged from the hospital after an eight-day inpatient stay for treatment of Heart Failure exacerbation (HF). This is Reggie’s fourth hospitalization for HF in the last three years. Prior to being hospitalized, Reggie noted that his legs became severely swollen, his abdomen was distended, and he started feeling short of breath. When his daughter brought him a meal, she noticed how swollen his legs were, and how ill he looked. She called his primary care provider, who suggested that Reggie be taken to the local ER. Soon after arriving at the ER he was admitted to the telemetry unit for treatment of an exacerbation of HF.

During his hospital stay, Reggie was treated with Lasix, potassium supplements, as well as his normally prescribed medications. The Lasix and potassium supplements were discontinued yesterday. He maintained a strict low sodium cardiac diet, with fluid restriction to 1500 cc per day. Additionally, Reggie and his daughter received education about lifestyle modification for HF and diabetes. Reggie will be discharged home today, with plans to see his cardiologist in one week, have laboratory blood draws in one week, and see his primary care provider as soon as possible. Reggie was treated by his usual cardiologist while in the hospital, and a hospitalist. Records of his hospitalization will be digitally sent to his primary care provider.

Reggie’s other history is as follows: Ht: 6’0”  WT: 265 BP: 112/74 Temp: 98.8 F  O2 sats: 96% on RA Pain: 0/10

Insurance: Medicare Advantage Plan (Coverage for A-D)

PMH: Hypertension for 40 years. Obesity (BMI 35.9 kg/m2). Hyperlipidemia. DM II. Appendectomy at 42. Bilateral osteoarthritis of the knees.

FH: Father deceased, lung cancer at 68. Mother deceased, MI at 80, DM II, HTN. Son, 47, DM II, hyperlipidemia. Daughter, 45, HTN. Son, 42, alive and well.

SH: Bachelors degree  in civil engineering. Retired civil engineer. Widower of 3.5 years, with three grown children. Oldest son lives out of state. Daughter lives in the same city. Youngest son lives several hours away. Reggie lives in the same home he has occupied for 40 years in a well-maintained neighborhood with wide sidewalks, two nearby parks, and several local grocery stores with a wide variety of fruits and vegetables, both are about one mile from his home. Reggie eats frozen and canned foods often, especially since his wife passed away from breast cancer 3½ years ago. He does not exercise regularly. No smoking history. Does not drink alcohol. One cup of coffee per day with sugar and creamer. No soda but does drink orange juice with breakfast and vegetable juice with his dinner. Reggie and his wife attended a local church weekly, he has attended sporadically since her death. Reggie used to participate in a local hobby builder group, but has not attended meetings for over a year. Other than his daughter nearby, Reggie has no extended family nearby.

Meds: Metoprolol XL 25 mg, 1 tab daily by mouth. Lisinopril 10 mg tab, 1 tab daily by mouth. Aspirin 81 mg tab, 1 tab daily by mouth. Aldactone 25 mg tab, 1 tab daily by mouth in the morning. Metformin HCl 500 mg tab, 2 tabs each am with breakfast, 1 tab each pm with dinner. Simvastatin 40 mg tab, 1 tab daily by mouth. Tylenol 500 mg tab, 1-2 tabs as needed by mouth for knee pain (do not exceed 3 grams daily).

Allergies: NKDA, No food allergies, minor seasonal allergies.