Date of Award

Spring 5-4-2018

Document Type

DNP Project

Project Team Faculty Member

Dr. Kathy Ketchum

Project Team Faculty Member

Dr. Mary Lee Barron

Project Team Faculty Member

Dr. Lisa Green


hospital readmission, patient discharge, communication, transitional care management, continuity of care, reducing readmission rates


Primary care providers are challenged to identify strategies to decrease hospital readmissions. Transitional care management (TCM) services can improve communication and allow primary care providers (PCP) an opportunity to meet with patients just after discharge to assess needs and prevent readmissions. A TCM protocol was evaluated at a large Midwestern clinic to determine if communication improved and readmissions decreased. The protocol consisted of notifying the PCP upon admission and discharge to the hospital, communicating with the patient or family within 48 hours of discharge, and facilitating a follow up visit with the primary care provider within 14 days of hospital discharge. Following implementation of the TCM, data was collected and analyzed using logistic regression analysis to determine the probable occurrence of the three variables on hospital readmission. The TCM was easily implemented with positive adherence to the protocol among providers. The presence of a 48-hour post discharge phone call was found to be the most effective intervention at preventing readmissions. Transitional care management protocols were found to provide beneficial continuity of care that could influence readmission rates. Further research is necessary to evaluate the effectiveness of TCM protocols.

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Problem Statement

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Clinical Relevance

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Literature Review

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Conceptual Framework

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Evaluation Process/Instruments

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Reference List

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