Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Jean Barry

Second Advisor

Patricia Thomas

Third Advisor

Kristine Todd


Hospital readmission, particularly within 30 days of discharge, is a wicked problem. Effective case management is an imperative component of high quality healthcare for the successful transition of patients across acute and post-acute settings. Patients with complex care needs endure an increased risk for negative outcomes, mortality, and hospital readmission. A small body of evidence suggests that early, targeted interventions aimed at high risk patients can mitigate complications and poor transitions. Patient complexity is an important consideration when establishing a comprehensive care management plan. Risk prediction tools are valuable for ensuring that high risk patients receive appropriate resource allocation. Case management processes must promote identification of patients with the most complex needs for the timely delivery of services that are nurse-coordinated, collaborative, and patient-centered.

The purpose of this scholarly project was to collaborate with the Case Management and Clinical Quality Management teams at an urban community-based hospital (CBH) to establish a standardized case management protocol for patients determined to be at high risk for mortality and readmission. Using the scores derived from a 30-day mortality risk prediction tool, PRISM, the project plan was to prioritize patients for case management services. The goal of this project was to augment current case management services to ensure that PRISM 1, 2, and 3 patients concurrently receive a standardized bundle of care and person-centered transition planning, beginning at the onset of the inpatient stay.

Included in

Nursing Commons