NURS FPX 4905 Assessment 4 Intervention Proposal

NURS FPX 4905 Assessment 4 Proposal for Intervention

Student name

Capella University

NURS-FPX4905 Capstone Project for Nursing

Professor Name

Submission Date

Proposal for Intervention

It is necessary to fill the continuity of care gap between patients who undergo detox to long-term care, as observed at Immersion Residential Center through a well-designed intervention. Most patients with substance use disorders (SUDs) are discharged without any specific, individualized follow-up plan that would put them at risk of relapse and unfavorable health outcomes.

The proposed intervention will help to enhance post-detox transitions, which will be achieved by introducing a standardized discharge procedure involving coordinated referrals, utilization of technology in the follow-up, and increased interprofessional cooperation. This practice suggests the evidence-based approach and contributes to the provision of high-risk patients with safe and patient-centered care.

Practice Issue of Concern

The selected practice problem of need is the absence of planned continuity of service to persons released during the detoxification process at Immersion Residential Center (The Immersion Program, 2025). Although one of the most important stages of SUD treatment is detox, not all patients are discharged with their own follow-up plan and a verified referral to outpatient or long-term rehabilitation services (David et al., 2022).

This disparity increases the likelihood of relapse and readmission into hospitals or even a lack of interest in treatment. Although there are electronic health records (EHRs) and teamwork, no standardized procedure can guarantee a smooth transition between levels of care, which undermines patient outcomes in terms of quality and safety.

The problem is especially important in terms of nursing leadership and practice since nurses who are prepared in the BSN are supposed to contribute to the adoption of quality improvement and represent vulnerable populations. The code of ethics provided by the American Nurses Association (ANA) assists nurses in making sure that the patient is not a victim of systemic gaps, particularly during the transitions that are characterized by high risks, such as post-detox discharge (American Nurses Association, 2025).

More than clinical care is needed to address this concern. It involves coordinated planning, communication, and incorporating supportive technologies to facilitate the shift between inpatient and outpatient services. Nurses can be at the forefront of addressing this problem to advance care continuity and increase the likelihood of long-term recovery in patients with SUDs.

Current Practice

The existing practice at Immersion Residential Center is a form of medically monitored detoxification and discharge without a detailed transition plan, usually with general verbal information or pamphlets instead of tailored, individualized transition plans (The Immersion Program, 2025). Even though the staff is composed of a multidisciplinary team, nurses, physicians, therapists, and case managers, a formalized or standardized system of providing follow-up care does not exist (Sheehan et al., 2021). Each provider approaches discharge planning removes, and although EHRs are utilized to record information about the patients, they are not always taken advantage of to facilitate referrals or liaise with other outpatient services.

There are some basic teletherapy options and case management support, although it is not a system that ensures every patient a clear, confirmed path to the next level of care. This leads to a high number of patients being released during detox without recorded referrals, scheduled outpatient visits, or relapse prevention plans (David et al., 2022). This practice inconsistency is part of the reasons why care is fragmented, leading to poor adherence to treatments and leading to relapse in individuals with SUDs.

Strategy to Improve Current Practice

As a solution to the problem of disjointed post-detox services in Immersion Residential Center, a tracked transition-of-care procedure is suggested. This plan is about making sure that all the clients who are discharged after having detox issues are given individualized and well-coordinated follow-up plans (Incze et al., 2024). This involves booking appointments with outpatient practitioners, mental health care, and providing the connections of the patients with the recovery support systems, like peer groups. Presently, there are a large number of people who are released without a definite follow-up, which exposes them to the risk of relapse or re-hospitalization.

The new protocol would entail an increased level of interprofessional cooperation between nurses, addiction counselors, and case managers, with the help of the standardized discharge checklist and improved EHR documentation procedures (Incze et al., 2024). This would make sure that the follow-up care is not planned but actually approved when a patient is leaving the facility.

• Changes Needed for People and Processes

To achieve this enhancement, the workflows and the positions of the staff will have to be redefined. The nurses would begin the discharge process during the early part of the detox stay, and the case managers would be involved in managing communication with other providers and community programs (Patel and Bechmann, 2023). Weekly, Interdisciplinary huddles would be introduced to monitor discharge preparedness and bring the staff on the same page regarding patient progress. It would involve an improvement of the EHR system by adding automatic alerts, referral documentation templates, and post-discharge tracking communication facilitation (Alexiuk et al., 2023). The strategies will help promote quality improvement as they ensure continuity of care, patient safety is promoted by participation in relapse prevention, and also healthcare costs are minimized by reducing emergency readmissions. Also, it promotes communication using technology and minimizes the load on emergency services and crisis centers.

• Assumptions

The approach presupposes that employees like nurses, therapists, and case managers are willing to implement a standardized discharge workflow through proper training. It also assumes that the EHR system of the facility can be used to support the custom templates and alerts for discharge coordination. It is also dependent on the accessibility and responsiveness of outpatient providers in order to accept the timely referrals. Lastly, it presupposes that patients with SUDs will remain more involved in recovery after they are discharged with organized follow-up and immediate assistance. The assumptions are consistent with the evidence that coordinated care enhances the results of post-detox.

Enhancing Quality, Safety, and Cost-Effectiveness

The adoption of a standardized discharge strategy in the Immersion residential center would go a long way in enhancing the quality and continuity of care provided to the SUD patients. Combining checklists, regular follow-up appointments, and EHR-generated alerts makes the approach reliable to ensure the absence of missing significant steps during the discharge (You et al., 2025). This minimizes readmission rates, enhances long-term recovery levels, and aids patient safety by ensuring that they get referred to mental health services and outpatient care promptly. Gaps in treatment are also reduced by using telehealth and care coordination platforms, particularly when treating individuals in remote locations to improve access to and compliance with treatment plans. Furthermore, early intervention will reduce relapses, which will reduce the spending related to emergency readmission and reclinides.

There are, however, challenges to the strategy. It involves initial overhead costs of training personnel, potential modifications of EHR, and time to establish interagency partnerships, which may initially overburden workflow and budgets. Digital inequity is also a possibility with certain patients not accessing telehealth or being digitally illiterate (Alkureishi et al., 2021). Although the drawbacks exist, the long-term outcomes, including fewer relapses, increased patient engagement, and lowered healthcare costs, outweigh the initial barriers and consider this strategy a viable and influential solution.

Application of Technology in the Strategy

The suggested plan heavily depends on the application of EHRs and telehealth platforms to improve the process of discharge planning and care coordination of patients who are recovering after SUDs. EHRs offer a unified system of documenting the discharge plan, establishing automated follow-up reminders, and enabling real-time communication within an interprofessional team (Robertson et al., 2022). This minimizes chances of miscommunication or missed referrals, thereby ensuring continuity of care. Also, with telehealth, patients can remotely communicate with outpatient providers, mental health counselors, and peer support networks, which is especially useful in underserved and rural communities.

Use of this technology is suitable as it directly acknowledges the current gaps in continuity of care after discharge, which is likely to cause relapse and readmission. The integration of EHR removes the issue of team members not having access to updated patient records and thus facilitating transparency and accountability. Small and secure messaging and mobile apps are also telehealth tools that enhance patient accessibility but preserve their confidentiality (Haleem et al., 2021). These technologies have low costs, are scalable, and are in line with the existing trends in digitization of healthcare, hence suit well to assist in supporting a sustainable, patient-focused model of discharge planning.

Implementation of Improvement Strategy at the Clinical Site

To adopt the improvement strategy in the Immersion residential center, the process would start with providing the structured interdisciplinary discharge planning protocols that would integrate EHRs and scheduled case conferences. The staff, nurses, therapists, and case managers would take part in training sessions to be familiar with digital tools, such as EHR-integrated care plans and telehealth coordination platforms, to ensure a consistent documentation approach, shared goal-setting, and familiarity (Zhang and Saltman, 2021). The interdisciplinary huddles would be conducted weekly to discuss the progress of patients and revise discharge plans to ensure a smooth flow of coordination with the outpatient and community services.

• Site-Specific Challenges and Solutions

One of the problems in this location is the low level of technological development and unreliable knowledge of digital documentation and telehealth applications by the personnel. Moreover, the low patient retention and inconsistent staffing can have an effect on the interdisciplinary meetings (Kwame and Petrucka, 2021). To address these problems, a slow introduction of the training on the EHR use and telehealth systems would be conducted, beginning with clinical leaders.

To simplify the communication process and to conduct a follow-up, a specific discharge coordinator or case manager may be appointed (Bechir & Bechir, 2025). The scheduling barriers could be addressed with the help of asynchronous communication tools, such as shared EHR notes or secure messaging applications, so that the patient-centered care planning process would be timely and collaborative.

Interprofessional Collaboration to Support Strategy Implementation

Interprofessional collaboration is an important factor in the effective execution of a discharge coordination strategy for people receiving detox and residential rehabilitation at Immersion Residential Center. Tight cooperation will guarantee that every team member, such as nurses, physicians, addiction counselors, therapists, case managers, and social workers, will contribute his or her knowledge to produce a full-fledged, personalized discharge plan (Noel et al., 2022). The practice can enhance continuity of care and lower the chances of relapse as well as long-term recovery by linking patients to suitable outpatient, mental health, and social services.

Interprofessional collaboration in this environment is not only a matter of communication, but a well-organized, regular, and involving process of planning. As an example, an interdisciplinary meeting every week, during which each provider reports and helps to achieve the goals of the patient, will guarantee that all areas of the patient, medical, psychological, and social, are covered (Bendowska & Baum, 2023). Shared EHRs also promote real-time dissemination of information, which minimizes duplications and miscommunications. Such coordination will enable early detection of discharge barriers and planning with external providers, including outpatient counselors or primary care physicians.

I have made contributions to my practicum by sharing observations, being a member of care teams, and facilitating documentation. Formally, as an RN, I would initiate the standardization of interprofessional discharge huddles, promote case management referrals at the early stages of treatment, and the creation of a culture of open communication in which all the input of the disciplines is appreciated. The last aspects of maintenance of collaboration include building trust among the team members and focusing on common patient goals (Abson et al., 2024). Finally, the combined team will boost patient outcomes, increase accountability, and simplify the process of transitioning inpatient care to community-based recovery services.

Conclusion

The suggested strategy will improve patient discharge coordination in patients receiving detox and residential rehabilitation by filling the existing continuity of care gaps. It is anticipated that patient outcomes, safety, and cost-efficiency will be enhanced through the application of structured interprofessional collaboration, the use of shared electronic health records, and planned case conferences. The intervention will facilitate a holistic, patient-centered approach to transitional care in environments of substance use disorder treatment, because it involves the use of technology and evidence-based interventions and proactive planning to overcome challenges associated with the specific site.

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NURS FPX 4905 Assessment 4 Narrative  

Introduction

• Slide 1

Hello, ladies and gentlemen! The proposal that will be presented today is as follows; I am presenting myself as being named as __________ and I would like to improve the outcomes and care delivery among the clients in our practicum site which is Immersion Residential Center. My practicum experience was based on the issue of substance use disorder (SUD) patients who are treated and the lack of continuity of care between residential treatment and post-residential therapy.

Such failures are likely to cause the emergence of the issue once again or a lack of commitment to the long-term recovery (David et al., 2022). My intervention will contribute to improving the process of transitional planning and integrating supportive technologies that have the potential to improve the recovery process, increase the level of safety, and eventually lead to a decrease in the level of readmission.

National Data

• Slide 2

On the national level, it can be indicated that almost 60 percent of people with SUD relapse in the first 30 days of leaving residential treatment (Estrellado, 2024). The lack of good engagement and follow-up support after discharge is also a trend with internal observation at Immersion Residential Center (The Immersion Program, 2025).

In addition, although electronic health records (EHRs) and simple teletherapy exist, such innovative tools as AI-based relapse prediction, wearable biosensors, and gamified recovery applications are still not implemented, even though there is growing evidence that they decrease the rate of relapse and help with lasting recovery. These statistics demonstrate that there is an urgent need to improve continuity of care that is more technology-focused and client-centric.

Problem Statement

• Slide 3

The main problem in Immersion Residential Center is that the relapse rate of the clients with SUD is high after discharge. Although there are certain underlying technologies, including EHRs and virtual therapy, there are still many gaps in the sustained and individualized care after treatment. Clients usually do not have real-time support tools, and the system is not proactive in detecting the risks of relapse (Olawade et al., 2024). This not only poses the threat of long-term recovery but also exerts a greater load on the emergency services, hence increasing healthcare costs and lowering the effectiveness of the treatment. The current model hinders recovery success due to a lack of innovation in the monitoring and engagement of the clients.

Proposed Solution

• Slide 4

To counter the above gaps, this proposal outlines a systematic discharge coordination plan targeting individuals with SUDs at Immersion Residential Center. The plan involves meeting cases before patient discharge, real-time updates on shared EHRs, and communication bridges between inpatient and outpatient providers, such as addiction counselors, therapists, and primary care physicians (Incze et al., 2024).

One of the RNs will act as the discharge coordinator and make sure that every patient has a unique plan, which will be based on medical, psychological, and social needs. It is necessary to eliminate the risk of care fragmentation after detox by this change, lower the relapse rates, and ensure long-term recovery. It is consistent with the evidence that coordinated discharge planning is associated with improved outcomes and fewer readmissions in SUD patients.

Benefits and Rationale for Implementation

• Slide 5

A systematized discharge procedure has several advantages for SUD patients. It leads to an improved quality and continuity of care, which means that the patients will not experience feelings of abandonment in the aftermath of inpatient treatment (Incze et al., 2024). The strategy also ensures the continuation of the recovery momentum by linking them directly to the outpatient providers and community support, thereby minimizing chances of relapse and re-hospitalization.

Moreover, an effective allocation of roles and health IT tools may enhance the efficiency of the staff and minimize miscommunication, which will eventually minimize the operational costs. The evidence behind this approach is that Wosny et al. (2023) state that the smooth transition of inpatient to outpatient care is essential to the prolonged recovery. Demonstrating the need to invest in discharge coordination is important not only to help patients but also to achieve such organizational goals as higher treatment adherence, higher levels of satisfaction, and a better reputation in behavioral health networks.

The Need for Change

• Slide 6

The SUD is a chronic public health problem, and even after inpatient treatment, a significant number of patients have disjointed follow-up treatment, which causes relapse or re-hospitalization. The current discharge protocol lacks any standardization in the practicum site, which leads to inconsistent planning, no accountability among the staff, and a lack of opportunities to provide long-term patient recovery support.

This gap has not only implications for patient outcomes but also implications for the healthcare system in terms of unnecessary costs and use of resources. The Substance Abuse and Mental Health Services Administration (2022) argues that patients with SUD require integrated and sustained care to maintain recovery after discharge. It is critical to implement an organized, evidence-based discharge planning method, which would help to make sure that the provided care is patient-focused, coordinated, and efficient.

Key Aspects of the Proposal

• Slide 7

This proposal is based on the implementation of a universal discharge planning process that specifically targets patients with SUD. The major elements are early detection of SUD patients, appointing a special case manager, developing a detailed care plan, scheduling community follow-ups, and incorporating telehealth check-ins to maintain the assistance. The proposed solution will help to provide continuity of care, better the long-term recovery rates, and decrease readmission. Through the engagement of an interprofessional team in the form of nurses, social workers, addiction specialists, and primary care providers, we will be able to provide holistic and coordinated care. This change will allow filling the existing gaps and enhancing patient satisfaction and efficiency in the system.

Reason to Implement the Proposal

• Slide 8

A systematic discharge strategy in SUD patients is essential since the existing piecemeal discharging methods are the cause of the high relapse and readmission rates. Research indicates that without both in-person and tele-based follow-up, post-discharge care, almost 40-60% of people with SUD revert to drug use within weeks because of the absence of follow-up, counseling, or continued care (Kabisa et al., 2021).

In this proposal, these gaps are covered by facilitating a smooth inpatient to community-based care, increasing patient engagement, and enhancing treatment adherence. Through the reinforcement of discharge practices, we enhance the outcomes of the SUD patients and decrease the healthcare costs, emergency visits, and inpatient burden, and thus create a more efficient and humane system of care.

Conclusion

• Side 9

To sum up, the suggested intervention seeks to enhance the discharge planning of patients with SUD in the Immersion Residential Center. This strategy can dramatically decrease the rate of relapse and enhance patient outcomes and resource utilization by introducing a structured and technology-supported process of discharge and promoting interprofessional collaboration. We should collectively go to introduce this significant change. Together with your assistance and commitment, we will develop a more integrated service network that will help our patients to be empowered in their recovery and allow them to have the continuity of care they rightfully deserve.