Date of Graduation

Fall 12-12-2014

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions



First Advisor

Dr. T. Godfrey

Second Advisor

Dr. G. DeBourgh

Third Advisor

Dr. A. Kwong


With the implementation of the Patient Protection and Affordable Care Act of 2010 (PPACA) and a national requirement for health care providers and systems to deliver care that is safe, outcome driven, and cost effective, Dignity Health (DH) as part of the hospital engagement network (HEN) launched an initiative called the “No Harm” campaign to reduce all-cause avoidable hospital readmissions. The project, led by a Doctorate of Nursing Practice (DNP) student and readmission team, sought to achieve a 20% reduction in preventable readmissions by December 2014. After having achieved initial success in implementing transitional care services for patients with heart failure and subsequently decreasing rehospitalizations by 30%, the DNP student and readmission team plan to expand evidence-based practices and interventions to all high-risk patients admitted to St. Mary’s Medical Center, a DH member. Such practices will include four key transitional care interventions: enhanced assessment of post-hospital needs, effective teaching and facilitated coaching (learning), post-hospital care follow-up, and provision of real-time handover to the next provider(s) to reduce avoidable rehospitalizations and improve outcomes.

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