Date Approved


Graduate Degree Type


Degree Name

Nursing (D.N.P.)

Degree Program

College of Nursing

First Advisor

Dr. Karen Burritt, PhD, RN, FNP-BC

Second Advisor

Dr. Rebecca Davis, PhD, RN

Academic Year



Background and Objectives: Great effort has been put into improving care transitions and supporting patients more effectively upon discharge from the hospital. With the hopes of improving outcomes and quality of life, while reducing hospital readmission, transitional care management has guided efforts to improve care delivery to those with chronic conditions. The purpose of this evidenced-base practice quality improvement project is to implement and evaluate Transitional Care Management services (TCMs) within a rural health heart failure (HF) clinic.

Problem: Although implementation of TCM is well supported in the literature, the organizational infrastructure to support it is lacking. The purpose of this project was to implement and evaluate TCMs as guided by the Transitional Care Model in a rural health clinic in the Midwest.

Methods: This quality improvement, evidenced-based practice project was intended to examine the impact of TCMs in a rural heart failure clinic. Participants included clinic staff and patients with a new diagnosis of heart failure (N=15). Application of a comprehensive workflow model supported many components of the Transitional Care Model including staff education, screening, engaging patients and caregivers, self-management, collaboration, and continuity of care. TCMs was implemented with a focus on workflow, post-discharge phone calls, follow up within 7-14 days, and charge capture.

Results: After the implementation of TCMs, 12 out of 15 patients received post-discharge phone calls, however, only 5 out of 15 were billed for TCM services. Follow up within 7-14 business days was completed on 6 of the 15 patients. Semi-structured interviews with patients and staff regarding care transitions demonstrated improvement post implementation.

Conclusions: With the successful implementation of TCM services as guided by the Transitional Care Model, patient satisfaction, provider knowledge, post discharge phone calls, charge capture and readmission rates improved for the small number of patients included in the project.

Keywords: Key Words: Transitional Care Management Services, transitional care, care transitions, chronic disease management.

Available for download on Saturday, May 10, 2025

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