Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Date of Graduation


Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing


Jeannie Garber

Debbie Kile


A national focus for healthcare reform is preventing hospital readmissions. Thirty-day unplanned hospital readmissions impact patient outcomes and are costly to the healthcare system. This project explored the impact between the discharge navigator and 30-day unplanned readmissions for heart failure and sepsis populations in a 238-bed community hospital located in central Virginia. The primary aim of this discharge navigator project was to reduce 30-day readmissions for the heart failure and sepsis populations to meet the goals of the top quartile for like hospitals and the evaluation of cost avoidance for these readmissions. Heart failure and sepsis populations are high risks for readmissions nationwide because they account for the largest frequency of unplanned readmissions within 30 days. Identification is an essential piece of reducing 30-day readmissions. The discharge navigator identified high-risk readmission patients that meet the inclusion criteria, developed a comprehensive discharge plan, collaborated with pharmacy services, and aided in the transition of care from acute care to home. There was a reduction in 30-day readmissions while the project was being implemented and the goal of top quartile for like hospital was met at the end point of the project. Potential cost avoidance sums can support the discharge navigator role. The discharge navigator project added to the body of knowledge for comprehensive discharge planning, coordination and education that is needed for these types of patient populations that have a great deal of medical complexity.



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