Inadequate discharge planning for individuals with chronic illnesses or injuries is associated with increased readmissions to the hospital or rehabilitation facility where the original treatments were administered. To help ensure the recovery of discharged patients and avoid readmissions, discharge planners guide medication and care processes. The rate of readmissions was high in a stand-alone rehabilitation center due to ineffective discharge plans. Patients, family members, and caregivers lacked knowledge about medications, treatments, and self-care guidelines after the patient left the facility. The purpose of this project was to ascertain the impact of improved discharge processes using the (a) IDEAL Discharge Planning Overview, Process, and Checklist; (b) the teach-back Method training for discharge nurses; and (c) the Postdischarge Rehabilitation Services Follow-Up Tool incorporating telephone calls to all participants during Weeks 1, 2, and 4 postdischarge. Lewin's theory of planned change undergirded this project. According to Centers for Medicare and Medicaid Services data, the rate of readmissions among the 50 participants was 4.4%, compared with 6% (all-facility readmission rate) during the same quarter of the prior year. Findings from this project suggest that reductions in readmissions were associated with improvements in discharge planning, training of caregivers, and the use of national tools to standardize practices in reducing readmissions. The implication of this project for positive social change is that patient-centered inpatient rehabilitation care and patient-centered care following discharge may reduce readmissions, reduce costs, improve reimbursement, and reduce deterioration of patients' conditions postdischarge.

Telehealth initiated a transformation in the realm of innovative strategies to meet the demands of an ever-changing health care system. Adapting provisions to new delivery care models such as telehealth is one way to improve access to care. The purpose of this project was to explore evidence of best practices in telehealth through an extensive, systematic literature review. The practice-focused question focused on identifying advantages of and barriers to the use of telehealth for improving patient satisfaction and quality of care. The plan-do-study-act cycle served as a model for accelerating quality improvement through improved systems of practice, and the Critical Appraisal Skills Program tool was used to identify factors in the literature that indicated the clinical effectiveness of telehealth and the contributions of information technology to patient outcomes throughout the care continuum. Applying Melnyk and Fineout-Overholt's model, which consists of 7 levels for grading evidence, 11 articles were identified as meeting the inclusion criteria. With respect to comparing telehealth services, this review identified areas for future research, including how telehealth can be used to bridge the gap between hospital and home with the integration of telehealth being integrated into routine care as a means to deliver medical, health, and educational services that contribute to improving patient outcomes. The implications of this project related to social change include supporting evidence that positive change is possible when modalities of health care delivery include the patient as part of care, benefiting both patient and provider.