Date of Graduation

Fall 12-11-2020

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


The timeliness of post-discharge outreach, a component of the Transition of Care (TOC) process, is a critical determinant for readmission. The Health Plan (HP) serves over 260,000 residents of a large San Francisco Bay Area county by working with community partners to provide health care services through its Medi-Cal (MC) and Cal MediConnect (CMC or Medicare-Medicaid Plan) insurance plan.

This project aims to reduce the HP’s readmissions by 1.5% to 7.37% from a baseline of 8.87% for CMC members and to 6.8% from a baseline of 8.3% for MC members within one year from the onset of the improved TOC process and implementation of new interventions, the first of which will be to make an initial outreach attempt within 48 hours.

Performance will be measured by monitoring the readmission rates at the hospitals within the HP’s contracted network and to track the timing of the post-discharge outreach calls and measure if they were completed within 48 hours post-discharge notification.

The expected results are that readmission rates will be down by 1.5% from the baseline and that there will be an annual net savings of $107,352. These results will validate the importance of post-discharge outreach as part of the TOC process and its effect on hospital readmissions. The efforts put forth by the Clinical Nurse Leader, Utilization Management, Case Management, and Quality Improvement imply that a collaborative interdisciplinary care team approach is essential to produce these outcomes.