NURS FPX 8045 Assessment 7 Literature Review

Name

Capella university

NURS-FPX 8045 Doctoral Writing and Professional Practice

Prof. Name

Date

Conceptualizing a Potential Project-Signature Assessment

A gap exists in the communication and collaboration between nursing staff and outpatient care providers during patient discharge at We Level Up Treatment Lawrenceville. Inconsistency in communication leads to negative outcomes such as increased hospital readmission rates for patients with Substance Use Disorders (SUD) (Sinclair et al., 2024). Implementing the Agency for Healthcare Research and Quality’s (AHRQ) Re-Engineered Discharge (RED) Toolkit can enhance discharge protocols by fostering improved communication and care coordination among healthcare providers, aiming to reduce readmissions (AHRQ, 2023). Addressing the communication and collaboration gap can lead to more consistent discharge practices at We Level Up Treatment Lawrenceville. PICOT question guiding DNP project is:

In nurses working in a drug and alcohol treatment facility (P), how does the implementation of the AHRQ’s RED Toolkit (I), compared to current discharge practices (C), affect hospital readmissions (O) over twelve weeks (T)?

Part 2: Analysis and Synthesis of Research

Literature on the practice gap at We Level Up Treatment Lawrenceville underscores the need for improved communication and collaboration between nursing staff and outpatient care providers, particularly during patient discharge. Identifying the practice gap has implications, as inconsistencies in discharge planning and follow-up care increase relapse risks and hospital readmissions among patients with SUDs. Synthesis of research on interdisciplinary collaboration, cultural responsiveness, leadership, and tailored collaborative care models provides moderate-quality evidence (SORT B) that supports the implementation of structured protocols and recovery-supportive interventions to bridge identified gap and enhance patient outcomes.

Sinclair et al. (2024), gave compelling evidence that underscores the value of recovery-oriented discharge planning in SUD, addressing the inconsistent communication and collaboration. Analyzing 25 studies reveals that post-discharge services, such as peer support, housing stability, and interagency collaboration, enhance long-term recovery outcomes by promoting trust and continuity of care. Findings strongly align with the needs at We Level Up Treatment, where fragmented follow-up care impedes recovery.

NURS FPX 8045 Assessment 7 Literature Review

A comprehensive review by Sinclair et al. (2024), supported a recovery paradigm, emphasizing the critical role of communication between providers and structured discharge processes. Moderate-quality evidence from the review substantiates the practice gap by showing that collaborative discharge planning can mitigate relapse risks and reduce hospital readmissions. While the review emphasizes effective discharge strategies, it lacks specific implementation methods tailored to different settings, particularly those with limited resources. Absence of resources creates a knowledge gap regarding how to adapt and apply communication strategies effectively in varied healthcare environments.

Osilla et al. (2022), offered insights into addressing co-occurring disorders such as Opioid Use Disorder (OUD) and mental health issues like PTSD and depression, which complicate discharge planning due to improper collaboration and communication. Osilla et al. (2022), adopted a collaborative care model in New Mexico that includes community health workers and measurement-based care to coordinate services more effectively for complex cases. Research is highly relevant to the practice gap at We Level Up Treatment, where nursing staff often encounter challenges related to co-occurring disorders among SUD patients.

Adaptation of the collaborative care model, titled CLARO, reveals that engaging community health workers in care coordination fosters patient acceptability and improves care accessibility, especially in low-resource settings. According to the SORT model, the moderate-quality evidence presented by Osilla et al. (2022), supported the use of tailored approaches to manage dual diagnoses and highlights the need for integrated care coordination. However, study’s reliance on a limited sample in a specific geographic area of Mexico limits generalizability, raising questions about the model’s applicability in more diverse settings and indicating a need for further research to evaluate the model’s adaptability across different patient populations.

NURS FPX 8045 Assessment 7 Literature Review

Interdisciplinary collaboration, as explored by Kools et al. (2022), provided another foundational approach for addressing the improper communication practice gap. Using a mixed-methods approach, they examined structured protocols in AUD treatment to improve outcomes through enhanced interdisciplinary communication. Social network analysis conducted within a hospital setting reveals that stronger relationships among network partners improve AUD treatment quality and reduce barriers to patient engagement.

Findings underscore the role of structured protocols and interdisciplinary teamwork, aligning with the need for standardized discharge protocols at We Level Up Treatment. Moderate-quality evidence from Kools et al. (2022),, suggested that establishing consistent proper communication channels among healthcare providers can strengthen team cohesion, promote seamless care transitions, and reduce fragmentation. The study does not fully address the way to practically implement the above-mentioned findings, especially in outpatient settings with limited resources and staffing constraints, indicating a need for further research.

NURS FPX 8045 Assessment 7 Literature Review

Hirchak et al. (2020) emphasized culturally responsive interventions as critical for effective communication and collaboration in SUD treatment, particularly within culturally diverse patient populations. Mixed-methods study by Hirchak et al. (2020), on culturally adapted SUD treatments for American Indian communities reveals that community engagement and cultural re-centering foster meaningful patient-provider interactions. Authors employ the Interactive Systems Framework to evaluate culturally relevant approaches, facilitate recovery and improve treatment efficacy.

Findings indicate that culturally adapted practices strengthen relationships between patients and providers, an aspect directly relevant to We Level Up Treatment, where multicultural considerations are essential in bridging the communication gap during patient discharge. Hirchak et al. (2020), provided moderate-quality evidence (SORT B) supporting the integration of cultural adaptations into discharge planning to foster better patient engagement and continuity of care. However, their findings highlight an area of uncertainty regarding the long-term sustainability of culturally adapted interventions, particularly in settings where cultural resources and personnel are limited. Further research is needed to evaluate the culturally responsive communication adaptations that can sustained and expanded across diverse SUD treatment settings.

Guerrero and Khachikian (2020), examined transformational leadership’s impact on communication and collaboration within SUD treatment programs. Applying case analysis methods grounded in transformational leadership theory, their study demonstrates that leadership styles emphasizing evidence-based practices and clear communication foster an organizational climate conducive to staff engagement and patient-centered care. Transformational leadership encourages trust and accountability, directly addressing the practice gap identified at We Level Up Treatment. Moderate-quality evidence indicates effective leadership can enhance team collaboration, especially in resource-limited SUD treatment facilities.

NURS FPX 8045 Assessment 7 Literature Review

However, while the study underscores the value of leadership in promoting collaborative care, it leaves questions about the feasibility of adopting transformational leadership strategies in settings with hierarchical or fragmented management structures. Additional research is needed to explore ways through which leadership training and development can be tailored to support collaborative care efforts in diverse SUD treatment environments. All studies mentioned above collectively highlight the need for structured discharge protocols, interdisciplinary teamwork, and culturally adapted approaches to support continuity of care and reduce relapse risks. Addressing knowledge gaps related to population or area chosen in studies will help We Level Up Treatment create recovery-supportive interventions, leading to improved continuity of care and reduced hospital readmissions among SUD patients.

Part 3: Recommendations to Stakeholders

Effective recommendations for addressing the communication and collaboration gap at We Level Up Treatment Lawrenceville require a structured, evidence-based intervention. RED Toolkit, an established intervention by the AHRQ, is recommended to enhance discharge processes and strengthen care transitions. RED Toolkit is a suitable choice given its comprehensive approach to discharge planning, which includes patient education, follow-up coordination, and standardized communication processes (Ștefan et al., 2024). Nursing staff at We Level, Up Treatment Lawrenceville, can deliver more consistent and coordinated discharge care, minimize miscommunication with outpatient providers, and help address challenges faced by patients with SUD by adopting the RED toolkit.

Studies reviewed underscore that the RED Toolkit’s structured discharge approach has been effective across various settings, achieving reductions in readmissions and improving communication. For example, research by Paolini et al. (2022), demonstrated a decrease in 30-day hospital readmission rates and enhanced collaboration between providers and patients through structured discharge protocols. Findings from Du et al. (2021) and Popejoy et al. (2021), supported the RED toolkit’s potential for increasing patient satisfaction and reinforcing provider communication, aligning with We Level Up Treatment Lawrenceville’s goals.

NURS FPX 8045 Assessment 7 Literature Review

Addressing the inconsistent communication and collaboration practice gap effectively, implementing the RED Toolkit requires steps targeting frontline nursing staff and outpatient providers. Leadership should begin by educating nursing staff on RED’s structured protocols, ensuring they understand each component and can consistently apply it. Training should emphasize strategies for effective communication with outpatient care providers and the importance of follow-up processes, which are crucial in reducing SUD patients’ relapse risk. Involving outpatient providers in the training process could strengthen the communication chain, creating a seamless transition from inpatient to outpatient care. Data on care outcomes and readmission rates would be essential to measure the toolkit’s impact (Mitchell et al., 2022).

Criteria for evaluating the intervention could include readmission rates within 30 days post-discharge, patient satisfaction scores regarding discharge clarity, and feedback from outpatient providers on care coordination. Establishing a pre-intervention baseline will allow for clear comparisons and an objective measure of the RED Toolkit’s impact (Arredondo et al., 2024). A 30 day readmission rate evaluation framework could benefit from real-time feedback loops, where nursing staff and outpatient providers can share insights on the toolkit’s effectiveness and identify potential areas for adjustment.

NURS FPX 8045 Assessment 7 Literature Review

Evidence from the reviewed literature shows a promising basis for this intervention, though some uncertainties remain, particularly in adapting the toolkit to SUD populations who face unique post-discharge challenges. Paolini et al. (2022) and Arredondo et al. (2024), emphasized that leadership commitment to training and adapting discharge protocols is crucial for achieving optimal outcomes. Mitchell et al. (2022) suggested that mental health considerations can impact discharge outcomes, which apply to patients with dual diagnoses of SUD and mental health conditions.

While current research supports RED as a general intervention, further studies could offer insights on tailoring it for populations with complex needs, such as SUD and concurrent mental health conditions, which would enhance its relevance to We Level Up Treatment Lawrenceville. Expanding the research on the way RED can best serve the SUD population could refine the intervention, particularly regarding specific communication strategies and follow-up support (Arredondo et al., 2024). Additional research could inform criteria for evaluating success, such as long-term readmission rates and patient engagement in follow-up services, thus allowing We Level Up Treatment Lawrenceville to further refine its discharge protocol.

Part 4: Communication with Stakeholders

Communicating effectively with the implementation team at We Level Up Treatment Lawrenceville, messages will be tailored to focus on the practical benefits of the RED Toolkit for enhancing discharge outcomes and team collaboration. Using clear, straightforward language, I will present the toolkit’s objectives and demonstrate the way each step supports smoother transitions and better outcomes for patients with SUD. Emphasizing roles and outlining individual responsibilities in the discharge process will help team members see their contributions to the success of the intervention. Visual aids, such as flowcharts or checklists, will simplify complex processes, ensuring clarity and reinforcing consistency in the new discharge protocol (Ștefan et al., 2024).

Addressing challenges like pushback or non-compliance will foster an environment of openness and mutual respect. Rather than enforcing compliance, team engagement can be encouraged by inviting feedback and addressing concerns early on. For example, if concerns about increased workload arise, explaining how the RED Toolkit’s structured approach can streamline tasks and improve patient care may alleviate apprehensions. Regular check-ins and creating a feedback loop will allow staff to voice challenges and suggest adjustments, promoting a sense of ownership and increasing long-term commitment to the RED toolkit intervention (Mitchell, 2022). Open communication and collaboration with the implementation team will be essential in creating a seamless transition to the RED Toolkit, aligning everyone’s efforts toward improved patient outcomes and successful discharge processes at We Level Up Treatment Lawrenceville.

Part 5: Feedback to Enhance Writing

In light of the course, feedback improved my writing qualitatively and positively impacted my analytical abilities. Instructor feedback on the assessment was useful in improving the organization and clarity of the work, especially through the MEAL plan of main idea, evidence, analysis, and link back. Using MEAL while synthesizing literature made it easier to organize sources with the argument and relate evidence with the main issues (Lindsay, 2020).

Feedback also included the need to use scholarly sources like Google Scholar and CINAHL, which improved the credibility of my work. Capella Library offered peer-reviewed articles that supplemented my argumentation when synthesizing literature and designing interventions. In future, feedback will continue to be my focus in my professional development. I will find a peer reviewer and mentor to help me in my career and use criticism to improve my daily communication. With feedback, I can make my writing informed and well-structured and conform to professional writing standards in the healthcare profession.

Part 6: Conclusion

In conclusion, addressing the practice gap at We Level Up Treatment Lawrenceville involves developing a clear and systematic intervention to enhance communication and collaboration in the patient discharge process. Research offers credence to the RED Toolkit as a useful model for strengthening discharge procedures, optimizing patient experiences, and decreasing the likelihood of readmission, particularly for SUD patients. Factors that emerged from the research analysis included nursing leadership, protocols, and communication channels to enhance the implementation process.

Research proved useful in offering information on minimizing care fragmentation and improving collaboration, which contributed to adopting the RED Toolkit. Identified practice gap should be addressed in future research that explores RED Toolkit implementations for SUD patients and long-term outcomes in various contexts. Healthcare teams can build upon the knowledge of the individual discharge strategies to improve the continuation of the recovery and care, thus increasing patient satisfaction and decreasing the relapse rate. We Level Up Treatment Lawrenceville.

References

AHRQ. (2023, April). Re-Engineered Discharge (RED) toolkit. Www.Agency for Healthcare Research and Quality.gov. https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html 

Arredondo, K., Renfro, D., Naungayan, A., & Renfro, D. (2024). Improving the discharge process at the VA Palo alto through change management and implementation of project re-engineered discharge. PubMed, 49(3), 95–100. https://doi.org/10.1097/rnj.0000000000000461 

Du, R. Y., Shelton, G., Ledet, C. R., Mills, W. L., Neal-Herman, L., Horstman, M., Trautner, B., Awad, S., Berger, D., & Naik, A. D. (2020). Implementation and feasibility of the re-engineered discharge for surgery (RED-S) intervention: A pilot study. Journal for Healthcare Quality, 43(2), 92–100. https://doi.org/10.1097/jhq.0000000000000266 

NURS FPX 8045 Assessment 7 Literature Review

Guerrero, E. G., & Khachikian, T. (2020). Leadership approaches to developing an effective drug treatment system. Effective Prevention and Treatment of Substance Use Disorders for Racial and Ethnic Minorities, 7. https://doi.org/10.5772/intechopen.91055 

Hirchak, K. A., Vallant, A., Herron, J., Cloud, V., Tonigan, J. S., McCrady, B., & Venner, K. (2020). Aligning three substance use disorder interventions among a tribe in the Southwest United States: Pilot feasibility for cultural re-centering, dissemination, and implementation. Journal of Ethnicity in Substance Abuse, 21(4), 1219–1235. https://doi.org/10.1080/15332640.2020.1836701 

Kools, N., Dekker, G. G., Kaijen, B. A. P., Meijboom, B. R., Bovens, R. H. L. M., & Rozema, A. D. (2022). Interdisciplinary collaboration in the treatment of alcohol use disorders in a general hospital department: A mixed-method study. Substance Abuse Treatment, Prevention, and Policy, 17(1), e59. https://doi.org/10.1186/s13011-022-00486-y 

Lindsay, D. (2020). Scientific writing = Thinking in words. In Google Books. Csiro Publishing. https://books.google.com/books?hl=en&lr=&id=XMrgDwAAQBAJ&oi=fnd&pg=PP1&dq=proper+structured+argument+and+clarity+in+the+words+&ots=XP1vxw_jyR&sig=iL4BsSVDZ3Kj_v07jl5YQcbfXrQ 

Mitchell, S. E., Reichert, M., Howard, J. M., Krizman, K., Bragg, A., Huffaker, M., Parker, K., Cawley, M., Roberts, H. W., Sung, Y., Brown, J., Culpepper, L., Cabral, H. J., & Jack, B. W. (2022). Reducing readmission of hospitalized patients with depressive symptoms: A randomized trial. The Annals of Family Medicine, 20(3), 246–254. https://doi.org/10.1370/afm.2801 

Osilla, K. C., Dopp, A. R., Watkins, K. E., Ceballos, V., Hurley, B., Meredith, L. S., Leamon, I., Jacobsohn, V., & Komaromy, M. (2022). Collaboration leading to addiction treatment and recovery from other stresses (CLARO): Process of adapting collaborative care for co-occurring opioid use and mental disorders. Addiction Science & Clinical Practice, 17(1), 25.  https://doi.org/10.1186/s13722-022-00302-9 

NURS FPX 8045 Assessment 7 Literature Review

Paolini, D., Bonaccorsi, G., Lorini, C., Forni, S., Tanzini, M., Toccafondi, G., D’arienzo, S., Dannaoui, B., Niccolini, F., Tomaiuolo, M., Bussotti, A., Petrioli, A., & Morettini, A. (2022). Careggi re-engineered discharge project: Standardize discharge and improve care coordination between healthcare professionals. International Journal for Quality in Health Care, 34(3). https://doi.org/10.1093/intqhc/mzac060 

Popejoy, L. L., Vogelsmeier, A. A., Wang, Y., Wakefield, B. J., Galambos, C. M., & Mehr, D. R. (2020). Testing re-engineered discharge program implementation strategies in SNFs. Clinical Nursing Research, 30(5), 644–653. https://doi.org/10.1177/1054773820982612

Sinclair, D. L., Chantry, M., Ruysscher, C. D., Magerman, J., Nicaise, P., & Vanderplasschen, W. (2024). Recovery-supportive interventions for people with substance use disorders: A scoping review. Frontiers in Psychiatry, 15. https://doi.org/10.3389/fpsyt.2024.1352818