Date of Award


Document Type

Scholarly Project

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Kathleen Farrell, DNSc, RN

Second Advisor

Lilian Chan, MSN, RN, PCCN-K


Ineffective discharge planning produces poor patient healthcare outcomes, potential adverse events, and medical errors. A primary deterrent to successful discharge planning is communication, either within the interdisciplinary team or during handoff to the receiving transition of care facilities of home health, skilled nursing, or acute rehabilitation.

The purpose of the evaluation project was to determine if current policies, communication tools, and workflows of three healthcare organizations were based on evidence and make recommendations for policy revisions. The Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals Model (JHNEBP) was used with the Centers for Disease Control (CDC) Policy Process (POLARIS) Framework in appraising the literature and guiding the policy evaluation. The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission (JC) were also included to support best practice recommendations.

The six best practice themes include early discharge planning, patient and care support engagement and education, established follow-up, consistent and timely communication of pertinent medical information, and standardized discharge planning. A Policy Evaluation Tool was developed to evaluate current healthcare policy against best practices criteria found in the evidence. Policy templates were specific to each healthcare organization with recommended revisions to current policy and discharge communication workflow. The recommendations were then vetted by each organization to incorporate the change policy into current practice.

The evaluation was beneficial to ensure the discharge planning process was current, relevant, and promoted best patient outcomes. Policy revision and current best practice evidence supports processes to prevent and avoid obstacles to proper transitional care.


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

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Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.