Date of Graduation

Spring 5-17-2019

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Francine J. Serafin-Dickson


Problem: Hospital readmission rates have been increasing for several years in the United States. With higher rates of rehospitalization, and for each home health payment episode being associated with a Medicare home health claim, there has been a greater incentive for these agencies to prevent patients from getting rehospitalized within 60 days of discharge. Besides the financial burden on the agency, rehospitalizations can have detrimental effects on the patients as well.

Context: Data from SHP says that California’s home health rehospitalization rates are at 14%, while this agency’s rates are at 16%. The goal of this agency is to match the state (California) rehospitalization rates – meaning the goal is to decrease patient rehospitalization by 2%, making the objective to have less than ten rehospitalizations per month. Audit results showed the reasons for the readmission, contributing factors that led to the readmission, as well as an analysis for clinical opportunities for improvement. This information helped form the interventions / next steps for the project.

Interventions: Several interventions were done to decrease rehospitalization rates: home visit checklist tool, audit tool, checklist for “SOC” reporting, follow-up phone call format, weekly rehospitalization meetings, and staff education.

Measures: Using SHP data to determine if there has been a decrease in the number of rehospitalized patients per month. Determine if the suggested interventions have decreased the home health agency’s rehospitalization rates.

Results: There was a decrease in hospital readmission rates after interventions were done.

Conclusions: A multimodal approach was the best way to tackle the rehospitalization issue and led to additional improvements in patient care and staff teamwork.

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