Date of Graduation

Fall 12-15-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Mary Seed

Second Advisor

Robin Jackson, MSN, RN, CNL



Problem – The rate of readmission in the country is at a severe level. According to CMS, in 2017 the average national readmission rate was 18.4%(CMS, 2018). Hospitals are penalized for unnecessary readmissions (HRRP, 2018). In addition to the financial burden of readmissions, quality of life is decreased with readmission.

Context – Early or timely outpatient follow-up after hospitalization has been projected as a means of decreasing readmission rates.

Interventions – Integrating follow-up appointment to the current care transition - HUB process as a means in reducing readmission rates.

Measures & Results – Identified high-risk patients that need timely follow-up appointment before hospital discharge. Through chart audits and call logs (from HUB Staff), 75% identified high-risk patients would have a scheduled follow-up appointment before hospital discharge.

Conclusions – Probable conclusions that can happen from this change in process project may be that there are external issues that prevent this change from happening. Discharged patients from hospitals that have higher early follow-up rates have a lower risk of 30-day readmission.