Advanced Health Assessment for Patients and Populations

Advanced Health Assessment for Patients and Populations D028 CPE Record

Phase One:

Criteria and elements by CMS in the HRRRP Program

The CMS HRRP program is dedicated to reducing hospital readmissions for certain diseases, such as heart failure and myocardial infarction, which have been reported to have high readmission rates within thirty days of discharge. The program motivates institutions to prevent hospital readmissions through payment reductions for excessive readmissions for the specific conditions listed by the CMS.

Advanced Health Assessment for Patients and Populations

The calculations and payment deductions apply to Medicare patients. The CMS calculates payment reduction based on performance after a rolling performance period. The CMS calculates payment reductions based on the excess readmissions using a payment reduction factor. The payment reductions are applied to all Medicare-related fee services based on the specific diagnosis. The highest fee deduction is 3% after a payment adjustment factor of 0.97.

The conditions under which payment reductions are made are “Acute myocardial infarction (AMI), Chronic obstructive pulmonary disease (COPD), Heart failure (HF), Pneumonia, Coronary artery bypass graft (CABG) surgery, and Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA),” (, 2022).

D028_CPE_Record Instructions

Care Transition Plan for a Patient with Myocardial Infarction

The patient of interest is a 55-year-old Hispanic male with MI. The condition is among the diseases with the highest readmission rates, primarily due to complications and lack of proper care and knowledge. Improving the quality of care during the transition from the facility to home is integral to promoting better patient outcomes and preventing readmissions.

There are various factors to consider for this patient during care transmission for this post-surgery MI patient. These include infection prevention, cardiac rehabilitation, prevention of MI recurrence, and health improvement. According to Hussain et al. (2018), medication adherence is one of the significant concerns in managing MI and preventing readmission secondary to disease exacerbations. In addition, cardiogenic shock is the most significant factor for readmission in MI patient readmission, accounting for about 20% of MI readmissions (Rymer et al., 2019).

The care transition plan will entail extensive patient education and connection with the primary care provider. The extensive education program will help the patient understand his condition, his role in care delivery, and the risk for readmissions, promoting their participation in care.

The education components include medication adherence, infection prevention, exercise and lifestyle modification, and care interventions (Rymer et al., 2019). Education o medication adherence will entail helping the client understand the importance of medications and the risks associated with poor adherence. Strategies that can help manage medication adherence include creating a routine and reminders to help remind the patient of their time to take medications without fail (Hussain et al., 2018).

The education will improve patients’ knowledge and promote their participation in care delivery. The teach-back method will help assess patients’ knowledge and understanding to ascertain their self-care ability. For this patient, educating the immediate family on care interventions with the patient’s consent is vital to promote better patient outcomes.

A one-month intensive weekly follow-up program will also help assess readmission risks using available tools and enhance continued patient education (De Luca et al., 2021). Physical follow-ups will also allow care providers to perform complete patient assessments and inspire patient participation in care delivery. The interventions will also help assess the effectiveness of care interventions and the need for change.

The patient has hyperlipidemia and is obese, which increases the risk for atherosclerosis which could precipitate secondary myocardial ischemia, myocardial infarction, and subsequent heart failure. Besides the current management interventions, this patient will require medications to help manage obesity. The patient is obese, for which he is receiving no treatment.

Obesity is a significant risk factor for primary health conditions such as heart disease, diabetes, cancer, and musculoskeletal conditions. Medications, dieting, exercise, and lifestyle modification will be vital for managing this patient and preventing health exacerbation.

Exercises for myocardial infarction rehabilitation range from low-energy activities such as eating and washing the face to high-energy activities such as jogging, depending on the patient tolerance and date post-surgery. The primary priority is to improve the quality of life after discharge and prevent readmission within thirty days post-discharge.

Another vital intervention for this patient is a referral to available community resources for myocardial infarction (De Luca et al., 2021). These resources include Advent Health Cardiovascular Institute and American Heart Association which help the patient access further care information. These resources will help patients access more detailed information about the management of their condition.

AHC1 also has patient support groups that offer patients emotional and social support. According to Haines et al. (2018), support and peer groups are vital community resources that help patients manage the psychological effects of particular diagnoses and help patients with disease prognoses. These interventions will promote better patient outcomes, increase access to care, and reduce readmission within 30 days post-discharge.

Phase Two

Evidence-Based Strategies in Reducing All-Cause Hospital Readmissions

Some evidence-based strategies include using risk assessment models, scheduling visits until recovery (physical and telehealth), education programs, community resources, and homecare extension programs. Risk identification models are evidence-based interventions that help assess risks for disease recurrence and the need for support to prevent all-cause hospital readmissions.

Smith et al. (2018) note that risk identification models for myocardial infarction help care providers assess risks for readmission and mitigate them. Risk assessment models for other conditions, such as heart failure and stroke, also exist, and care providers use them to assess patient risks and manage them before discharge.

Risk management models assess social, physical, physiological, and environmental factors and help develop interventions to manage them. Numerous risk assessment models/tools are used for each condition, and the knowledge of these risks and their utilization are integral in proper patient planning and prevention of readmissions.

For a long time, follow-up visits have been standard care in patient management. Research shows that these visits help professionals assess patient response to treatment interventions and determine patient risks (Tong et al., 2018).

Tong et al. (2018) show that strategic follow-up reduces patient readmission or incidences by over 30% and promotes better patient outcomes post-discharge. The new CMS policies have extended payment for telehealth visits to increase health equity and care access during COVID-19. The CMS enumerates telehealth visits similar to physical visits hence improving their utilization.

Telehealth visits allow patients with less access to healthcare facilities to access care interventions such as assessment and consultation (Cortes-Penfield et al., 2021). Telehealth patient visits have been integral in promoting quality patient outcomes and reducing patient readmission.

Hospitals have education policies that improve patient education and promote better patient outcomes. Standardized technologies on interventions such as wound care, medication administration, and self-assessment (such as breast self-assessment terminology) can enhance patient education.

Patient education algorithms for specific patient needs and conditions can help simplify and make patient education effective. These algorithms will ensure the education interventions capture all patient care components on patient needs and health conditions.

One effective standardized technology in patient education is diabetes self-management education (Bekele et al., 2020). Standardized terminologies in education slightly differ from routine education based on its organization and ability to improve knowledge and self-care. Bekele et al. (2020) show that DSME improves patient glycemic control outcomes, knowledge, and self-care compared to routine care. Patient education often lacks organization, and it is thus easy to leave out vital details necessary for better patient outcomes.

Another intervention is asthma and COPD management and exacerbation prevention programs. The algorithms/terminology teaches patients how to avoid allergens, recognize asthmatic attacks, and use the correct technique to administer medications during attacks (Collinsworth et al., 2018).

Education also influences the quality of shared decision-making and patient involvement in care delivery. Patient education increases knowledge and skills to change perspectives and promote care collaboration. Patient education begins at admission and persists until the care provider-patient interaction ends.

Policies guiding patient education from admission to discharge will help ensure adequate patient guidance and quality outcomes by the end of the interactions (Collinsworth et al., 2018). The education policies should also incorporate family education programs as mandatory interventions to ensure quality care outcomes and effective care transition from home to the health facility.

Homecare extension programs are care interventions that promote better patient outcomes. Homecare extension programs entail professionals such as nurses and physicians. These programs allow institutions to assign homecare nurses to patients for whom they are responsible for essential healthcare interventions.

Nurses and physicians assess patients based on their specific needs. These interventions range from education, and medications, to minor procedures such as sutures removal and wound dressing using aseptic procedures (Siclovan et al., 2021).

The intervention enhances care continuity at home, especially for chronically ill and elderly patients. Extension programs also help patients access vital resources and care connections that are unavailable in normal circumstances. With these programs, patients who require acute inpatient services may be treated at home, preventing exacerbation and readmissions (Siclovan et a., 2021). These extended home care programs/care packages are common among elderly patients with complex needs who can benefit from care in their homes.

Community resources are an integrated, evidence-based strategy for all chronic and high-risk recurrence diseases. Patients with chronic illnesses such as diabetes and cancer often require much care and assistance to achieve high-quality lives and prevent readmissions.

Groups such as the AA have helped individuals recover from alcohol addiction and the subsequent consequences, such as accidents, lost jobs, social isolation, and readmission due to alcohol intoxication (Kelly et al., 2020). These social groups join individuals with similar problems and ambitions who help and encourage each other through recovery.

Other funding agencies and governments support some support groups. Other resources include online resources, which entail evidence-based information from reputable websites such as American Heart Association. Referral to online resources is a widely acceptable intervention and helps improve patient knowledge and subsequent health outcomes (Gardener et al., 2020).

These agency websites contain information gathered from research that can help individuals live positive lives free of disease. The resources also supplement patient education, and guiding patients to the right websites to ensure access to correct information helps enhance their knowledge of correct practice, promote better patient outcomes, and reduce hospital readmissions.

Individual, Community, System, and Social Determinants of Health Considerations That Impact All-Cause Readmission and their Prevention 

Major social determinants of health affecting readmissions include education levels and income. Patients without adequate knowledge of managing their health often have poor outcomes, hence the need for extensive patient education.

Patient level of education is also a significant predictor of pre-existing knowledge and patient outcomes (Zhang et al.., 2020) Low-income families have trouble accessing health facilities and implementing interventions such as daily dressing and accessing hospitals (transport). Supporting these families to access Medicare and Medicaid Services under the ACA can help improve their health status.

According to Glans et al. (2020), health insurance coverage is one of the most important predictors of healthcare services utilization. Health insurance coverage helps individuals access healthcare services because these services are paramount. Insurance will also increase access to telehealth services, an effort necessary to prevent readmissions.

Cultural practices have a considerable bearing on hospital readmissions. Practices such as wound care, diet, medications, and other care interventions, and exercise are affected by cultural practices, values, and norms. Rayan-Gharra et al. (2019) note that culture makes implementing interventions such as dieting challenging and could make patient recovery difficult, leading to readmissions.

Recognition of culture and how it affects care for these patients and their families can help improve care interventions for these patients. Family education can help them accept care interventions and prevent readmissions for these patients (Rayan-Gharra et al., 2019). Patients and their families can be educated on the importance of avoiding some practices that can place the patient at risk for health deterioration hence promoting better patient outcomes.

Community factors such as distance from healthcare facilities and the availability of equipped care facilities also affect health access and utilization (Spatz et al., 2020). Patients from remote areas can suffer from poor access to healthcare facilities hence poor outcomes.

Other factors, such as community perception of the hospital, also play a huge role in service utilization and readmission rates (Spatz et al., 2020). Telehealth visits and patient follow-ups are promising interventions to ensure continued follow-up and attention. Hospitals can also develop extension programs where they offer transport services to their most needed clients.

Programs such as Deaconess Health System’s Helping Hand program have successfully offered transport to patients attending Deaconess hospitals at affordable fees compared to other transport interventions, considering the different patient needs. These programs facilitate movement and can be used to improve patient outcomes. Thus, these individual, social, community and social determinants of health affecting patient readmission can be effectively managed.


Development of a Hospital Prevention Plan

The hospital should develop an HRRP extension program to prevent primary, secondary, and tertiary hospitalization. The program will help prevent illnesses, diagnose illnesses early, and prevent readmissions. The first intervention is mandatory health screening.

The screening interventions will follow the United States Preventive Services Taskforce (USPSTF) recommendations. Developing screening programs for heart, cancer, obesity, and hypertension will help prevent these diseases. Patient management will also be based on the recommendations of the USPSTF for various conditions.

The interventions aim to reduce the burden of chronic illnesses and their population health and economic implications to the patients and the healthcare institutions (Walensky & Paltiel, 2019). Implementing large-scale screening interventions for diseases such as tuberculosis, HIV, and diabetes has helped institutions diagnose patients early and promote better patient outcomes.

Walensky and Paltiel (2019) note that HIV tracing and screening under USPSTF has helped reduce the incidence rates and promote better patient outcomes through early detection and initiation of treatment.

The second intervention in the extension program is the creation of hospital dashboards that show care providers the daily, weekly, monthly, ad yearly performance against the local and national benchmarks on the hospital’s performance based on patient readmission.

Renowned databases such as the HRRP and NRD by the AHQR keep information on patient readmission and are vital sources for this intervention. Park et al. (2019) note that small data such as patient monitoring post-admission can help track health status, predict risks for readmission and prevent readmission rate.

According to Wong et al. (2020), healthcare institutions can develop dashboards stemming from national dashboards that help track patient data and influence their health outcomes. The dashboard will be a constant reminder of the hospital’s performance as it will outline the current performance and influence action.

For tertiary prevention, a home care package for patients is necessary to reduce all-cause hospital readmissions. The program will entail extensive patient education at discharge, risk assessment, and follow-up interventions based on the risk assessment results.

Besides the routine follow-up, the hospital will create a risk assessment tool for healthcare conditions to help healthcare providers assess the risk for readmission and recruit patients in the home care extension program. The risk assessment will ensure cost-effectiveness in the effort to reduce readmissions.

The follow-up will entail telehealth and physical visits where nurses and physicians will assess patients, plan care interventions, and refer them to access quality healthcare services where needed (Stammer, 2018).

Stammer (2018) notes that telehealth technology has the potential to improve patient care outcomes through early consultation and referral, and its flexibility also increases its utilization. As discussed earlier, homecare extension programs offer patient care equivalent to care at the facility but in familiar environments hence better patient outcomes.

King et al. (2022) note that care providers (nurses and physicians) teach patients how to improve their self-care acuity, improve self-management, and promote better patient outcomes. The comprehensive program healthcare assessment dashboard and screening based on USPSTF recommendations will help improve primary, secondary, and tertiary health and reduce hospital readmissions. The interventions will thus improve health outcomes and reduce payment reductions implemented by the CMS HRRP program.

Phase 3 Reflection

The CPE was an overall pleasant experience. From the CPE, I learned that numerous interventions target better health outcomes for populations. The interest condition was Myocardial Infarction. The first component of the care transition was to ensure the patient receives adequate care, such as medications and assistance with activities of daily living, such as feeding.

The following intervention addressed the recovery to everyday life by assessing possible risks and their mitigation and care collaboration by other sectors. The other intervention was to maintain the gained health outcomes for the patent through access to resources and prevention of exacerbation.

From this phase, I learned that patient outcomes post-discharge is vital to institutions and go beyond payment deductions. Healthcare professionals should work with multidisciplinary teams to prevent hospital readmissions through aggressive interventions such as screening and homecare to ensure better patient outcomes and overall population health outcomes.


Bekele, B. B., Negash, S., Bogale, B., Tesfaye, M., Getachew, D., Weldekidan, F., & Balcha, B. (2020). The effectiveness of diabetes self-management education (DSME) on glycemic control among T2DM patients randomized control trial: systematic review and meta-analysis protocol. Journal of Diabetes & Metabolic Disorders19(2), 1631-1637.

Center for Medicaid and Medicare Services (CMS), (2020). Hospital Readmissions Reduction Program (HRRP). Acute Inpatient PPS.

Collinsworth, A. W., Brown, R. M., James, C. S., Stanford, R. H., Alemayehu, D., & Priest, E. L. (2018). The impact of patient education and shared decision-making on hospital readmissions for COPD. International Journal of Chronic Obstructive Pulmonary Disease13, 1325.

Cortes-Penfield, N. W., LeMaster, M., & Alexander, B. (2021, November). 606. Implementation of a telehealth-based OPAT early post-discharge clinic may reduce hospital readmission. In Open Forum Infectious Diseases (Vol. 8, No. Suppl 1, p. S405). Oxford University Press.

De Luca, L., Paolucci, L., Nusca, A., Putini, R. L., Mangiacapra, F., Natale, E., … & Gabrielli, D. (2021). Current management and prognosis of patients with recurrent myocardial infarction. Reviews in Cardiovascular Medicine22(3), 731-740.

Gardner, R. L., Pelland, K., Youssef, R., Morphis, B., Calandra, K., Hollands, L., & Gravenstein, S. (2020). Reducing hospital readmissions through a skilled nursing facility discharge intervention: a pragmatic trial. Journal of the American Medical Directors Association21(4), 508-512.

Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge–a comparative retrospective study. BMC geriatrics20(1), 1-12.

Haines, K. J., Beesley, S. J., Hopkins, R. O., McPeake, J., Quasim, T., Ritchie, K., & Iwashyna, T. J. (2018). Peer support in critical care: a systematic review. Critical care medicine46(9), 1522-1531.

Hussain, S., Jamal, S. Z., & Qadir, F. (2018). Medication adherence in post myocardial infarction patients. Journal of Ayub Medical College Abbottabad30(4), 551-556.

Kelly, J. F., Abry, A., Ferri, M., & Humphreys, K. (2020). Alcoholics anonymous and 12-step facilitation treatments for alcohol use disorder: A distillation of a 2020 Cochrane review for clinicians and policy makers. Alcohol and alcoholism55(6), 641-651.

Park, C., Otobo, E., Ullman, J., Rogers, J., Fasihuddin, F., Garg, S., Kakkar, S., Goldstein, M., Chandrasekhar, S. V., Pinney, S., & Atreja, A. (2019). Impact on readmission reduction among heart failure patients using digital health monitoring: feasibility and adoptability study. JMIR medical informatics7(4), e13353.

Rayan-Gharra, N., Balicer, R. D., Tadmor, B., & Shadmi, E. (2019). Association between cultural factors and readmissions: the mediating effect of hospital discharge practices and care-transition preparedness. BMJ Quality & Safety28(11), 866-874.

Rymer, J. A., Chen, A. Y., Thomas, L., Fonarow, G. C., Peterson, E. D., & Wang, T. Y. (2019). Readmissions after acute myocardial infarction: how often do patients return to the discharging hospital? Journal of the American Heart Association, 8(19), e012059.

Siclovan, D. M., Bang, J. T., Yakusheva, O., Hamilton, M., Bobay, K. L., Costa, L. L., Hughes, R. G., Miles, J., Bahr, S. J., & Weiss, M. E. (2021). Effectiveness of home health care in reducing return to hospital: Evidence from a multi-hospital study in the US. International Journal of Nursing Studies119, 103946.

Smith, L. N., Makam, A. N., Darden, D., Mayo, H., Das, S. R., Halm, E. A., & Nguyen, O. K. (2018). Acute myocardial infarction readmission risk prediction models: a systematic review of model performance. Circulation: Cardiovascular Quality and Outcomes11(1), e003885.

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Advanced Health Assessment for Patients and Populations – D028 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.