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


This project focuses on the CNL curriculum element of Care Environment Management. The purpose of this project is to reduce hospital readmissions in geriatric patients who are currently having any changes of medical condition within the SNF microsystem. In this project, the CNL functions as the team manager and care coordinator. The CNL facilitated, and utilized patients’ outcome data to make changes in care processes to reduce acute hospital transfers in the skilled nursing facility. The CNL lead the interdisciplinary team and was resource or point of contact for this project. The CNL educated nurses to utilize (Interventions to Reduce Acute Care Transfers) INTERACT™ Early Warning Tool. Roger’s Diffusion of Innovation was the theoretical framework for this project.

Root cause analysis (RCA) was done, to identify contributing factors that lead to an increase incidences of avoidable hospital transfers and readmissions. Both internal and external data in the SNF’s microsystem identified a common theme, lack of in communication between social services (discharge planners), nursing, and physicians. . After consideration of the INTERACT tool the DON and CNL identified the two INTERACT communication tools and two INTERACT decision support tools to implement. Some examples of the INTERACT tools are shown in Appendix G. The INTERACT tools are designed to improve the identification, management, communication, evaluation, and documentation about acute changes in patients condition (Ouslander et al., 2011). The plan is to decrease acute hospital transfers and admissions by 2%. INTERACT toolkit, improved workflow for nursing staff and decrease avoidable hospital transfers.

In March of 2016, 12.31% of patients were transferred to the acute from the SNF environment; as of July 2016, the percentage of acute hospital transfers has decreased significantly to 5.36%. Goals and objective for this project was to decrease acute hospital transfers by 2%, currently hospital transfers have decrease to 6.95%. This exceeds the two percent benchmark that was set prior to the implementation of this CNL project.


Ouslander, J. G., Diaz, S., Hain, D., & Tappen, R. (2011). Frequency and diagnoses associated with 7- and 30-day readmission of Skilled Nursing Facility patients to a nonteaching community hospital. Journal of the American Medical Directors Association. doi:DOI:10.1016/j.jamda.2010.02.015