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Doctor of Nursing Practice
Family Nurse Practioner
Year Degree Awarded
Month Degree Awarded
DNP, transitional care, rehospitalization, readmission, heart failure, COPD
Advisor Last Name
Chandler, PhD, RN
Capstone Chair First Name
Capstone Chair Last Name
Chandler, PhD, RN
Capstone Member Name
DeMartinis, PhD, FNP, RN
Capstone Outside Member Name
ABSTRACT: TRANSITIONAL CARE FOR PATIENTS WITH CHRONIC DISEASE
BACKGROUND OF PROBLEM:
The Affordable Care Act of 2010 has put a spotlight on ensuring safe patient transfers between health care settings to prevent rehospitalization. Hospital readmissions are often influenced by a lack of outpatient transitional care programs to ensure the continuity of care during the transition from the inpatient setting to home. This gap in continuity further exacerbates the issues of patient management of medication regimens, adverse drug events, and follow-up with providers. These exacerbations combined with ineffective symptom management can all result in decompensation and rehospitalization. An extensive review of the literature revealed that transitional care interventions provide innovative and evidence-based methods to prevent the readmission of patients with chronic diseases. Transitional care is defined as a time-limited, patient-oriented service, intended to ensure health care continuity, reduce risk of poor outcomes among at-risk populations, and facilitate safe and effective transfer between levels of care or healthcare settings.
To assess the impact of a DNP-led Transitional Care Program (DNP-led TCP) designed to reduce the number of hospital readmissions of elderly patients discharged from a Cape Cod Hospital with a diagnosis of HF or COPD-related illnesses by addressing the complexities of transitions of care.
Twelve patients with HF or COPD related diagnoses participated in a DNP-led TCP. A prospective one group pre-test, post-test design was used to evaluate the impact of the intervention. The DNP-led TCP blended the concepts of CTM® and Naylor’s APN-led TCM and modified them for use in the community setting. The primary outcome measures of 30-day rehospitalization rates for HF and COPD-related illness and 30-day rehospitalization rates for all-causes were collected for the 30 days prior to implementation and 30 days post completion of the TCP. Data was obtained through patient reports and hospital and clinic records. The impact of the TCP on use of emergent or urgent care services for HF or COPD-related symptoms among clinic patients was determined by the percentage of patients in the TCP that documented or reported the use emergent or urgent care services for HF or COPD-related symptoms during the 30 days pre and post TCP.
Descriptive analysis was used to examine the change. At the end of the program, the data revealed a decrease from 20 readmissions to zero readmissions in a 30 day period for HF or COPD-related illness. There was a decrease in all-cause readmissions from 21 to zero in a 30 day period. The TCP had a dramatic impact on the use of emergent or urgent care services for HF or COPD-related symptoms among clinic patients. There were 24 visits to the ER among participants in the 30-days prior to the pilot. Eight visits were related to HF, one to an allergic reaction, and 15 were related to COPD. At the day 30 post implementation data collection, ER utilization had rate dropped to zero for HR or COPD related symptoms. This meets the goal of is ≤ 5% of patients receiving the intervention.