Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Karen Burritt

Second Advisor

Jean Barry

Third Advisor

Karen Lund


Healthcare in the United States is changing from a fee-for-service to a value based healthcare delivery system. One area of national focus is reducing 30-day hospital readmissions by providing high-quality transitions-of-care. Patients leaving the hospital without proper assessment of home care needs, patient education, and coordination of care run into barriers managing health conditions, which contributes to hospital readmissions. Poor transitions-of-care contribute to deterioration of health leading to acute care utilization and hospital readmissions, which is costly for healthcare organizations, insurance payers, and individuals. In 2017, the value based healthcare structure will be decreasing reimbursement to hospitals that have 30-day hospital readmissions higher than the national average. Providing high-quality transitions-of-care is a way to bring value to a health care delivery system. The Agency for Health Research and Quality and Centers for Medicaid and Medicare Services have significant evidence that implementing the Reengineered Discharge process and utilizing the Transitional Care Management program reduces 30-day hospital readmissions and acute care utilization through the provision of high-quality transitions-of-care. This quality improvement project standardizes all hospital discharges by incorporating the Reengineered Discharge process and includes eligible Medicare recipients in the Transitional Care Management program. This project increased the number of patients who received followup appointments, follow-up phone calls, and patients included in Transitional Care Management. Follow-up appointments for inpatient status increased by 22.5% and follow-up phone calls increased by 16.7%, enabling billing for seventeen Transitional Care Management patients.

Included in

Nursing Commons