First Advisor

Berg, Barbara

Second Advisor

Gilbert, Marsha

Third Advisor

Wimett, Lynn


Rueckert-Hartman College for Health Professions

Degree Name

Doctor of Nursing Practice


Loretto Heights School of Nursing

Document Type

Thesis - Open Access

Number of Pages

75 pages


One in five Medicare patients is readmitted within 30 days of a previous hospitalization, which impacts patients and the healthcare system with exponential expenditures (Allaudeen, Vidyarthi, Maselli, Auerbach, 2011). The Centers for Medicare and Medicaid Services have mobilized recovery audits to begin recapturing funds related to readmission, and medical institutions must take an active role to ensure their financial integrity and protect their clinical reputation. For the purpose of this project, the population of interest was Medicare beneficiaries age 50 through 88 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF). The intervention included post discharge phone calls to patients within 72 hours of discharge. The goal of this intervention was to evaluate if post discharge patient satisfaction phone calls reduced readmission for Medicare beneficiaries with a pathology of COPD or CHF. The objectives of this capstone project included identifying descriptive characteristics of Medicare populations diagnosed with COPD or CHF, determining the follow up needs of patients diagnosed with CHF or COPD post discharge, and assessing the congruence between expected readmission and observed readmission. The results of this study concluded that CHF patients who received a post discharge phone call experienced a decrease in readmission rates (intervention: zero readmissions vs. baseline value: 28.0%). COPD patients, however, had a readmission rate of 28.6% (compared to baseline value: 25.0%). COPD patients had a greater variation in post discharge needs compared to the CHF group. Further evaluation is warranted to understand disease specific care transition needs.

Date of Award

Fall 2012

Location (Creation)

Colorado (state); Denver (county); Denver (inhabited place)

Rights Statement

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