Abstract

Acute care healthcare organizations struggle to identify and implement interventions to support the transition of care between hospital and home settings. One organization piloted a quality improvement (QI) project using nurse-led post-discharge telephone consultations to determine their feasibility and effect as a transition of care intervention. The QI pilot was designed to answer the clinical question: does the receipt of nurse-led post-discharge telephone consultations improve patient satisfaction and 30-day readmission rate outcomes? The goals of the pilot were to investigate the feasibility of conducting the intervention, identify transition of care gaps, and evaluate the effect on 30-day readmissions and patient satisfaction. Prior to implementation of the pilot, patient satisfaction scores associated with care transitions ranged from 29.9-58.3%; they rose to 65.7and 65.5% 30 and 60 days respectively after the intervention was initiated. 30-day readmission rates on the pilot unit ranged from 0.1238-0.1354 in the months preceding the pilot; they fell to 0.1153 and 0.0615 30 and 60 days respectively after the intervention was initiated. The intervention uncovered opportunities to better support patients in the community, which is possibly more important than small improvements in patient satisfaction scores and readmission rates. The intervention can be an invaluable tool as acute care organizations strive to better care for people within their communities.

Author Details

Dinah Steele, DNP, MSN, RN, CMSRN

Sigma Membership

Non-member

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Other

Research Approach

Translational Research/Evidence-based Practice

Keywords:

Transition of Care Intervention, Nurse-Led, Post-Discharge Telephone Consultations

Advisor

Mindy Stayner

Second Advisor

Jill Schramm

Third Advisor

Cynthia May

Degree

DNP

Degree Grantor

Capella University

Degree Year

2017

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.

All permission requests should be directed accordingly and not to the Sigma Repository.

All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Self-submission

Date of Issue

2017-09-12

Full Text of Presentation

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