Date of Award
Summer 7-16-2024
Document Type
Scholarly Project
Degree Name
Doctor of Nursing Practice (DNP)
First Advisor
Dr. Mary Brann
Second Advisor
Dr. Kelli Lipcomb
Abstract
Unplanned hospital readmissions often result from poor discharge planning and challenges during the transition from hospital to home, including medication errors and weak communication with primary care providers. A well-organized and personalized discharge plan can significantly reduce hospital stays, lower readmission rates, minimize medication errors, and improve patient outcomes, all while decreasing healthcare costs. In post-discharge Medicare-eligible patients (P), how does transitional care coordination through organized, personalized, and patient-focused discharge planning (I), compared with standard or no transitional care coordination provided (C), affect readmissions (O) within the 30-day post-discharge phase monitored over a 10–12-week period (T)? A search was conducted using five databases: CINAHL, DynaMed, ProQuest, PubMed, and Google Scholar. The keywords included transitions of care, readmission prevention, and care coordination, focusing on articles published between 2018 and 2024. Inclusion criteria were articles about individuals in the United States, published in English, and peer reviewed. Articles concerning participants under 18 were excluded to maintain result integrity. Using tools like scoring systems, clear protocols, tool kits, and guidelines for coordinating care in the 30 days after discharge has proven to be very effective. These holistic approaches are easy to implement with limited resources and working with the interprofessional team ensures better outcomes and ultimately lowers the readmission rate. This project was aimed to determine if implementing a structured care to transitions of care coordination would reduce hospital readmissions. A formative evaluation enabled the facility to assess changes and make necessary adjustments, ensuring that clinical practice guidelines effectively achieved the desired outcomes. Formalizing Transitions of Care (TOC) coordination is a vital intervention that improves patient outcomes. The program offers a range of clinical interventions aimed at enhancing quality of life and prognoses. By adhering to established guidelines, it ensures patients receive necessary services for recovery and home management while minimizing risks for all parties.
Recommended Citation
Granado, B. (2024). Transitions of Care and the Prevention of Readmissions. [Doctoral project, University of St Augustine for Health Sciences]. SOAR @ USA: Student Scholarly Projects Collection. https://doi.org/10.46409/sr./HXXF4687
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.
Included in
Community Health and Preventive Medicine Commons, Health Services Administration Commons, Health Services Research Commons, Quality Improvement Commons
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.