Date of Graduation

Summer 8-9-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Nancy Taquino


Implementing Risk Tools to Prevent Hospital Readmission

Tara O’Connor


Background: Readmission reduction is one of the most important opportunities for reducing cost in today’s health care system.

Global Aim: To operationalize risk tools to reduce hospital readmissions by 5 percent by the end of 2017.

Project Aim: To develop new transitions program (TP) processes that operationalizes the risk tools and ensures 70 percent of all readmission risk score patients referred receive a post discharge phone call within 48 hours, and are assessed for their risk of medication management issues as part of their initial assessment, by August 1st, 2017.

Setting: The TP provides short term case management for patients transitioning home from hospital and other level of care.

Quality Gap: An evidence-based means of identifying patients at risk for readmission and a standardized process for assessing medication management issues was previously lacking.

Evidence: Intervention demonstrated in clinical trial to reduce readmissions requires timely post discharge follow-up, assessment of and interventions for medication management issues, education on the plan of care, and interventions that address the social barriers of health maintenance and promote patients’ and their caregivers’ capacity for self-management.

Results: Through clinical leadership, utilization of the Institute for Healthcare Improvement’s (IHIs) model for improvement, and interdisciplinary collaboration, the TP team has developed new processes that preliminary data suggests are accomplishing the project aim.

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