Date of Award
Fall 12-1-2020
Document Type
Scholarly Project
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
First Advisor
Debbie Conner, Ph.D., MSN, ANP/FNP-BC, FAANP
Second Advisor
Juana Cantu-Cabrera, DNP, WHNP, ANP, APRN, NP-C
Abstract
Practice Problem: The 30-day readmission rate for patients discharged from the hospital and returned to their primary care in a clinical office setting (21%) was higher than the national average readmission rate (17%). The high readmission rate suggested patients were receiving transitional care that was fragmented and non-standardized. Therefore, the implementation of a collaborative transition of care practice was vital to reduce avoidable readmissions.
PICOT: The PICOT question that guided this project was, “In adult patients with chronic conditions, what is the effect of a transition of care practice, versus a non-standardized practice, on reducing 30-day readmissions, within a 30-day period?”
Evidence: Evidence suggests that implementing a multidisciplinary Transition of Care practice for patients who are discharged from the hospital to home decreases the 30-day readmission rate. Intervention: Using a multidisciplinary approach, the registered nurse implemented a Transition of Care practice, consisting of 10 evidence-based interventions, applied to help the patient transition from hospital to home.
Outcome: The results of this project revealed a decrease in the 30-day readmission rate from 23% to 15%. Also, seven of the 10 interventions were successfully implemented at a rate of higher than 85%.
Conclusion: The reduction in the percent of 30-day readmissions was statistically and clinically significant between the pre-transition of care and the post-transition of care participants. In addition, the transition of care interventions were successfully implemented to standardize an evidence-based practice for patients transitioning from the hospital to their home.
Recommended Citation
Ramos, R. (2020). Transition of Care for Discharged Patients. [Doctoral project, University of St Augustine for Health Sciences]. SOAR @ USA: Student Scholarly Projects Collection. https://doi.org/10.46409/sr.JLOK5085
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.
Comments
Scholarly project submitted to the University of St. Augustine for Health Sciences in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice