Date of Graduation

Fall 12-13-2019

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Problem: Hospital readmission rates have steadily climbed in the United States and the cost of unplanned readmissions can be detrimental. It has been identified that greater discharge preparation and quality care coordination greatly impacts the patient’s plan of care and reduces the risk of unplanned 30-day readmissions. Transition programs help reduce the psychosocial barriers that prevent patients from being able to self-manage their conditions outside the acute setting and help patients effectively navigate the through the continuum of care.

Context: Research has shown that when the social determinants of health (SDOH) barriers are identified appropriately and early-on, this can decrease a patient’s risk of unplanned readmission. Audit results show opportunities for improvement in the program through development of a screening tool that will help clinicians appropriately identify psychosocial issues and increase educational awareness of the Transition Program (TP) as well as SDOH.

Interventions: Several interventions were done to help increase low-elevated transitional support level referrals to TP: development of a psychosocial assessment tool, in-service meeting to review the referral process of the TP, and staff education to raise awareness and importance of identifying SDOH in patient care outcomes.

Measures: Using HealthConnect and EPIC data to track weekly number of referral cases. Monitor if the development and implementation of the tool has increased the number of lowelevated TSL referrals to the Transition Program.

Results: There was a 25% increase in low TSL referrals. Clinicians reported increased awareness and knowledge about SDOH and Transition Program interventions.

Conclusions: Readmission and identifying SDOH barriers is a complex challenge to healthcare and requires interdisciplinary team collaboration and multimodal interventions.

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