Date of Graduation

Fall 12-17-2021

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Prof. Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC



Problem: The current predictive risk tool in use by the hospital case managers has demonstrated poor sensitivity and specificity in appropriately identifying patients with congestive heart failure who are at risk for readmissions resulting in both decreased and inappropriate referrals to the Transitions Care.

Context: The setting is a 153-bed community hospital in Northern California with an average of 9,500 admissions yearly. CHF readmissions account for approximately 4% of annual admissions.

Interventions: Interventions tested concurrently for a period of twelve weeks included the addition of the social determinants of health (SDoH) into the current predictive risk model tool supported by structured daily communication between the referring inpatient team and the transitions of care team prior to the patient’s hospital discharge.

Measures: The primary outcome for this quality improvement project is an increased number of appropriate referrals to the Transitions Care team in hospitalized patients with congestive heart failure.

Results: A 50% increase in appropriate CHF referrals to the Transitions of Care team was achieved by incorporating SDoH in the predictive risk tool and supported with daily structured communication between teams prior to the patient’s discharge.

Conclusions: Increased and appropriate referrals to the transitions of care teams in patients with CHF who are at risk for readmission can be achieved through structured communication and the use of tools that incorporate SDoH as important predictors of readmission in hospitalized CHF patients.

To download restricted works from off campus you must have a USF email address and use it to create an account for the repository.

  Contact Author