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Date of Graduation
Doctor of Nursing Practice (DNP)
School of Nursing
Sharon Strang Zook
Background: Today’s healthcare climate is comprised of a population of patients who are more complex, presenting with multiple comorbidities, and requiring frequent hospitalizations. It is imperative for acute care and primary care landscapes to bridge silos and form collaborative relationships to ensure safe and effective transitions of care from hospital to home. An interprofessional, post hospital follow-up clinic is one approach that can be utilized to improve transitions of care and decrease preventable hospital readmissions.
Purpose: The purpose of the project's discharge clinic was to improve transitions of care and decrease thirty day hospital readmission rates. The primary objective of the clinic was to utilize an interprofessional care team (Nurse Practitioner, Clinical Pharmacist, Nurse Case Manager, and Social Worker) to improve transitions of care post-hospital, for complex care patients.
Methods: The project utilized an innovative, interprofessional care team to help improve transitions of care. The interprofessional care team consisted of a Certified Family Nurse Practitioner, Clinical Pharmacist, Nurse Case Manager, and Social Worker. Upon hospital discharge, patients were offered a post hospital appointment with the identified care team. Patients were encouraged to be seen within 72 hours after hospital discharge to assess clinical status and to identify any barriers to the treatment plan in a timely manner.
Results: A comparative analysis was performed between national benchmark thirty day hospital readmission rates and the project's readmission rates. 2013 national, hospital wide thirty day readmission rates were reported at 13.9% across all expected payers. National thirty day readmission rates were examined for Medicare and Private coverage payer plans; 2013 rates were 17.3% and 8.6% respectively (Agency for Health Care Quality and Research, 2013). Project participants achieved a thirty day readmission rate of 2.7%.
Conclusions: The findings of this project suggest that post hospital clinics staffed by interprofessional teams may play a significant role in improving transitions of care. The interprofessional clinic was effective in decreasing hospital readmissions and served as a cost effective model of care that can be replicated across other health systems.
Baldwin, Stacy M., "Implementing post-hospital interprofessional care team visits to improve transitions of care and decrease hospital readmission rates" (2016). Doctor of Nursing Practice (DNP) Final Clinical Projects, 2016-2019. 1.