First Advisor

Cullen, Patricia L.


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

50 pages


“Readmission of Medicare patients within 30 days of discharge from the hospital is nearly 1 in 5” (Naylor, 2012). The older adult has become vulnerable to the ever present breakdowns in the healthcare system creating serious gaps in services. Society and social services have not maintained the continual rapid steady growth of services to the older adult to match the increased life span of Americans. As Rennke (2013) reports, “Patients are vulnerable to a wide range of adverse events after discharge, with more than 20% of medical patients sustaining a preventable adverse event within three weeks of discharge” (p.433). Ineffective care transitions have many contributing factors including lack of crucial communication between health care providers, unclear medication changes at time of health status change, patient perspective on medical diagnosis, lack of adequate follow-up needs including physician visits, and incomplete or unfinished diagnostic work-ups.
The purpose of the Capstone Project was to reallocate staff to develop and implement a transitional nurse team. The outcomes improved care transitions post hospital discharge.
The goals of the Capstone Project addressed three main imperatives of cost reduction, revenue growth, and clinical transformation.
The objectives of the Capstone Project included improvements in the hospital discharge process to enhance a seamless continuum of care.
The DNP Project Process Model (White & Zaccagnini, 2014) was used as the guideline for the Capstone Project. Steps I & II: Problem recognition and needs assessment completed after identifying need to decrease the hospital 30-day readmission rate; problem statement written; and systematic literature review completed. Step III: Goals, Objectives, and Mission statement developed. Step IV: Theoretical underpinnings chosen supporting Capstone project. Step V: Work plan completed including timeline, budget, and written proposal. Step VI: Logic Model (Zaccagnini & White, 2014) developed and evaluation plan completed. Step VII: IRB approval obtained from Regis University and Organization chosen for site of the project. Inclusion criteria and data collection tools developed and implemented.
Outcomes and Results
A total of 42 patients received interventions. A comparison group was selected meeting the same inclusion criteria without the interventions from a Transitional Nurse. The comparison group was provided the standard case management process for monitoring during hospital stay and discharge. Data analysis revealed significant correlation of multiple study variables at the 0.05 level using a 2-tailed test and reduction of 30 day readmissions post hospital discharge. Collaboration was instrumental to the success of this project.

Date of Award

Fall 2015

Location (Creation)

Denver, Colorado

Rights Statement

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