Document Type
DNP Project
Publication Date
2026
Degree Name
Doctor of Nursing Practice
Faculty Advisor
Dr. Susan Penque, PhD, ANP-BC, NE-BC, NC-C, TOC
Practice Mentor
Dr. Dara Richards, MD, FAAP
Abstract
Title: Transitional Care Telehealth Calls to Improve Hospital Follow-Up in a Community Health Center: A Quality Improvement Project
Background/Introduction: Transitions from hospital to primary care are a vulnerable period associated with missed follow-up appointments, poor patient outcomes, and increased readmissions, particularly in underserved populations. Internal data identified gaps in timely post-discharge follow-up, while external evidence supports structured transitional care interventions, such as telephone outreach within 48–72 hours, to improve patient engagement and continuity of care.
Objective/Purpose: The purpose of this quality improvement project was to evaluate whether structured, nurse-led transitional care telehealth calls improve completion of primary care follow-up visits within 7 days of hospital discharge.
Methods: Guided by the Institute for Healthcare Improvement Model for Improvement and the Plan-Do-Study-Act (PDSA) cycle, a standardized telephone call intervention was implemented at an urban community health center. Adult patients (≥18 years) discharged from the hospital were identified via the electronic health record. Nurses completed structured calls within 48–72 hours post-discharge, including medication reconciliation, patient education, and facilitation of follow-up appointment scheduling. Data were collected on call completion, follow-up appointments scheduled and attended, and adherence to the intervention process.
Results: The intervention demonstrated partial improvement in follow-up attendance among patients successfully contacted. However, overall outcomes were inconsistent and did not fully meet project objectives. Barriers such as limited staffing availability, competing clinical priorities, and inconsistent adherence to the call protocol impacted implementation effectiveness.
Conclusion: Transitional care telehealth calls represent a feasible, low-cost strategy to improve care coordination and patient engagement in underserved settings. While the intervention showed strong potential, consistent implementation, clear role ownership, and integration into clinical workflow are essential for achieving sustained improvement. Future efforts should focus on enhancing implementation reliability and evaluating long-term outcomes, including readmission rates.
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Recommended Citation
DeJesus, V. (2026). Transitional care model telehealth calls to improve hospital follow-ups in a community health center: A quality improvement project [Unpublished DNP project]. Sacred Heart University.
Comments
A DNP project submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice, Sacred Heart University Davis & Henley College of Nursing.