Multidisciplinary Transitional Care Program Implementation: Training Agenda for Heart Failure Readmission Reduction
Overview
This document outlines a structured training agenda for implementing a Multidisciplinary Transitional Care Program (MTCP) designed to reduce 30-day heart failure readmissions and achieve CMS Hospital Readmissions Reduction Program (HRRP) compliance. The training equips a pilot team of nurses, social workers, pharmacists, and physicians with knowledge and practical skills through lectures, skills practice stations, and role-based demonstrations.
What this coursework covers
- Introduction and MTCP overview establishing links between program implementation and institutional HRRP penalties
- Understanding MTCP core provisions including teach-back education, medication reconciliation, SDOH screening, and follow-up scheduling
- Roles and responsibilities defining discipline-specific duties and interprofessional communication protocols
- Training strategies including brainstorming sessions, hands-on skills practice stations, and return demonstrations with competency assessments
Preview
Annotated Training Agenda
Objective:
To equip the pilot team, nurses, social workers, pharmacists, and physicians, with the knowledge and skills needed to implement the Multidisciplinary Transitional Care Program (MTCP), reduce 30-day heart failure readmissions, and achieve compliance with CMS Hospital Readmissions Reduction Program (HRRP) benchmarks.
Date, Time, Duration:
TBD (to be scheduled by unit manager); two sessions of 60 minutes each (120 minutes total); conducted in the hospital classroom or simulation lab. Attendance records maintained by the charge nurse/educator.
Training Agenda
Training Agenda Outline | Annotation |
Introduction Welcome and overview of the MTCP training session. Importance of the MTCP and its impact on reducing preventable heart failure readmissions and achieving HRRP compliance. | Duration: 15 minutes. Facilitator: Unit Educator. Resources: HRRP policy one-pager handout, MTCP overview slides. Setting: Classroom. Purpose is to build buy-in by linking the MTCP directly to institutional HRRP penalties and improved patient outcomes. |
Understanding the MTCP Brief overview of the MTCP’s purpose: reduce 30-day HF readmissions through structured transitional care coordination. Key provisions: teach-back education, medication reconciliation, SDOH screening, timely follow-up scheduling, and ERR tracking to meet HRRP benchmarks. | Duration: 20 minutes. Facilitator: Clinical Nurse Educator. Resources: Visual flowchart of MTCP workflow, printed HRRP data handout. Learner success measured by a brief 5-question written knowledge check at the end of this segment. Continuing education credit: 0.5 CE hours. |
Roles and Responsibilities Pilot team includes: bedside nurses (teach-back education), pharmacists (medication reconciliation), social workers (SDOH screening), and physicians (care plan sign-off and follow-up orders). Each discipline reviews their specific MTCP duties: completing discharge checklists, documenting in the shared dashboard, and coordinating handoffs. More Nursing samples |