Care Transitions: Are Healthcare Organizations Meeting the Needs of Their Patients?
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Acute care healthcare organizations struggle to identify and implement interventions to support the transition of care between hospital and home settings. One organization piloted a quality improvement (QI) project using nurse-led post-discharge telephone consultations to determine their feasibility and effect as a transition of care intervention. The QI pilot was designed to answer the clinical question: does the receipt of nurse-led post-discharge telephone consultations improve patient satisfaction and 30-day readmission rate outcomes? The goals of the pilot were to investigate the feasibility of conducting the intervention, identify transition of care gaps, and evaluate the effect on 30-day readmissions and patient satisfaction. Prior to implementation of the pilot, patient satisfaction scores associated with care transitions ranged from 29.9-58.3%; they rose to 65.7and 65.5% 30 and 60 days respectively after the intervention was initiated. 30-day readmission rates on the pilot unit ranged from 0.1238-0.1354 in the months preceding the pilot; they fell to 0.1153 and 0.0615 30 and 60 days respectively after the intervention was initiated. The intervention uncovered opportunities to better support patients in the community, which is possibly more important than small improvements in patient satisfaction scores and readmission rates. The intervention can be an invaluable tool as acute care organizations strive to better care for people within their communities.
|Type||DNP Capstone Project|
|Review Type||None: Degree-based Submission|
|Research Approach||Translational Research/Evidence-based Practice|
|Keywords||transition of care intervention;
post-discharge telephone consultations
|CINAHL Subject(s)||Transitional Care;
Readmission--Statistics and Numerical Data;
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