Date of Graduation

Summer 8-15-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Carlee Stewart Balzaretti


When 84 patients, current and former, complained about lack of information during the intake process within five months period, a uniform "Patient Screening Tool" (Appendix L) was developed to improve the admissions process to this home health agency. Intake staff is responsible for receiving accurate information from the referral sources, confirming qualifications to receive services, and initiating education about services to the patient. While the population served has a wide range in age, diagnoses, discharge settings and cultures, the majority are over 65, frail, homebound and are returning home after hospital, SNF or rehabilitation settings.

Data were collected through evidence based practice research; informal surveys prior to developing the Patient Screening Tool, and clinicians’ interviews. Senge’s (1990) ‘Learning Organization theory and Ladder of Inference’ facilitated the implementation of this tool. The Ladder promotes independent thinking from all stakeholders. Direct observation and coaching encourage ongoing teaching between intake staff and nurse leader. Competency 8, evaluate patient handoffs and transitions of care to improve outcomes of Essential 3: Quality Improvement and Safety, was applied to determine the successful use of the Patient Screening Tool.

Assessment of this project was not completed due to resistance to change from the source that would provide approval. The“Patient Screening Tool” and the surveys are in process. The Patient Screening Tool will be used but no follow up surveys relayed to effectiveness were approved.

Limited informal discussions support the acceptance of the form as an improvement in the intake process however a formal survey has not been successfully implemented. The recommendation is to continue to encourage everyone involve in intake to use this tool to ensure seamless education and uniform accuracy of information during the patient's transition period from referring setting to home health care.