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Date of Award


Degree Type

Restricted Evidence-Based Project Report

Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Carole A. Pepa


Readmission rates are being monitored by hospital systems to maximize levels of reimbursement. Transitional care models identify problems that occur in the post hospital discharge period and posit the necessity to improve transitions from one level of care to another by being cost efficient without decreasing quality. The Care Transitions Intervention® is a transitional care model that is implemented for 30 days post hospital discharge. Its goals are to provide increased education, coaching, and support by a Transitions Coach® to high risk, complex clients. Numerous studies have supported that implementing the Care Transition Intervention® has significantly reduced 30 day hospital readmissions. This evidence-based practice project was conducted to determine if implementing the Care Transitions Intervention® for an additional 30 day time period would reduce readmission within 60 days of hospital discharge in high risk patients 65 years and older. After completion of the initial 30 day Care Transitions Intervention®, eligible clients had a home visit conducted by the DNP student within 10 days and two follow up phone calls. Population characteristics included: Caucasian (93.3%); Medicare as the primary payer (86.7%); married and lived with their spouse (73.3%); female (60%); primary diagnosis of congestive heart failure (CHF) (46.7%); and mean age of 75.5 years. An independent t test confirmed there was no difference between the clients in the project and the comparison group from 2011. To determine if implementing an additional 30 days of the Care Transitions Intervention® on high risk clients would decrease readmission within 60 days of hospital discharge, logistic regression was conducted with no significant effect on 60 day readmission significant (R2 =.632, F=(1,15)=15.012, p =.377). This project posits that conducting The Care Transitions Intervention® during the initial 30 days post discharge has the greatest impact on readmission rates. Furthermore, the risk factors identified in the literature may not be accurately capturing the characteristics of clients that are readmitted.


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