Date of Award
Doctor of Nursing Practice (DNP)
Debbie Conner, Ph.D., MSN, ANP/FNP-BC, FAANP
Juana Cantu-Cabrera, DNP, WHNP, ANP, APRN, NP-C
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.
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
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