Date of Graduation

Summer 8-12-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Dr. Cathy Coleman



Problem: Transitional care programs have increased in popularity to focus on optimizing transitions of care from acute hospitalization to home based settings to reduce hospital readmissions. The transitional care model utilized at this urban, integrated health facility is mostly 100% telephonic, short term (30 days) case management. Approximately 30% of the patients referred to the program have a diagnosis of congestive heart failure.

Context: Hospital reimbursement has decreased due to high readmissions rates, especially among congestive heart failure (CHF) patients. This process improvement project was aimed at decreasing CHF related readmissions through educating patient/families on CHF watch symptoms and increasing their confidence in managing their chronic conditions.

Intervention: The intervention utilized was a smart phrase addition that standardized case management assessment of heart failure and assigned a patient activation score regarding self-management of the chronic condition. Creation of and utilization of a smart phrase addition to the regional assessment dot phrase that standardizes management of heart failure highlighted evidence-based areas that could lead to readmission.

Measures: Primary measure was the reduction of the all-cause CHF readmission rate.

Process measures: I. Increase average patient readiness score by 3 points and II. 85% utilization of smart phrase by RN case manager for appropriate CHF patients.

Results: Primary measures cannot be analyzed as no readmission data is currently unavailable at time of submission. Regardless, the low number of patients who received the disease specific assessment is too low to correlate with any changes in readmission rate.

Process measures: I. patient activation score increased by average of 1.88 points which is below goal of 3.0 points. II. Smart phrase utilization was 70.83% of qualified referrals (N=24).

Conclusions: The data obtained, and feedback received showed disease specific assessments can be beneficial in case management especially when coupled with motivational interviewing. The addition of standardized scripts and smart phrases to HER documentation is encouraged.

Keywords: transitional care, post discharge follow up, motivational interviewing