Date of Graduation

Summer 8-7-2018

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Mary Seed

Second Advisor

Catherine Coleman


The prevalence of readmission and patients who are at high risk of readmission have been intensified and widespread due to the high rate of re-hospitalization in the U.S. A high rate of readmissions reflects on poor quality care and suboptimal patient outcomes. Payers have imposed financial penalties on hospitals with a high frequency of readmissions. The transition of patients from the acute care setting back to the community is a vulnerable period. To engage hospitals to develop plans to lower their rate of readmissions, the government introduced a readmission reduction program that will provide incentives to hospitals that adopt a new and effective comprehensive care transition program. This improvement project was conducted by a Case Manager (CM) acting in a Clinical Nurse Leader (CNL) role in an integrated delivery system to optimize care transitions. Using a systems approach, the CM/CNL functioned in the mesosystem to implement a new intervention to advocate for the inclusion of the “patient voice” to support decreasing readmissions and to better understand the gaps in care delivery. Informational interviews were conducted to determine patient perception related to their repeated hospitalization. Results indicated multiple opportunities for improvement related to communication, self-management, and appropriate length of stay. Across the microsystems in this setting, a nurse navigator role is strongly recommended to enhance the care transitions seamlessly across the continuum.

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