Date of Graduation

Winter 12-15-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone



Background: Within the organization, the estimated cost of readmissions is $10,107.00 per day. Managing readmission rates within the hospitals has been challenging due to multiple factors. Readmissions cause financial and emotional stress on patients and their families, along with the stresses experienced during hospitalization.

Problem: The yearly readmission goal for the Transitions Care Department is below 14% per month. In 2022 the Transitions Care Department has been above 14% for most of the year, averaging 17%. Hospital readmissions impose a substantial financial and resource burden on the healthcare system.

Interventions: Staff training will ensure their effectiveness in carrying out responsibilities. They will make at least two weekly calls to medium and high-risk patients, with daily call tracking. Standardized documentation for CHF and sepsis diagnoses will be implemented. Transitions Care Managers will actively participate in readmission calls and engage in discussions. CHF patients will receive scales for weight monitoring, and medication reviews will be conducted during calls. Transitions Care Nurses will interview readmitted patients to understand contributing factors.

Outcome Measures: The specific aim of this project is increasing call frequencies to high and medium risk patients to reduce avoidable readmissions below 14% per month from current baseline of 17%, by June 2023 in the East Bay Transitions Care Department.

Results: In April and June, the main outcome results achieved were below the targeted threshold of 14%. Overall, staff feedback on the project has been positive, noting the increased call frequency's remarkable impact on trust and patient relationships. While the project alone may not be the sole cause of the positive impact on readmission rates, it undoubtedly contributed significantly. Concurrently introduced initiatives have also played a role in improving outcomes.

Conclusion: The Transitions Care staff's commitment to calling patients twice weekly has reduced readmissions and improved patient outcomes. Continuing with these calls and complementary initiatives promises further progress. This proactive approach enhances care quality and patient satisfaction while addressing readmission challenges. Expanding the initiative to other Transitions Care Departments can extend its success.

Keywords: Transitions Care Department, readmissions