Document Type
DNP Project
Publication Date
2025
Degree Name
Doctor of Nursing Practice
Faculty Advisor
Chrystyne Olivieri, DNP, FNP-BC, CDCES
Abstract
Background
Within the United States, adult patients over the age of 65 are averaging give emergency room visits per year with potential admission. Patient hospital readmissions occur when a patient is discharged from the hospital and is readmitted within 30 days. This can occur due to medication noncompliance, premature discharge, or the most common reason, lack of adequate provide follow-up as an outpatient.
Project Goals
1. Implement a transitional care management screening tool within the primary care practice with Medicare adult patients with chronic conditions to improve post hospitalization follow up appointments with PCP.
2. Designate a medical assistant to take on the role of TCM representative within the office and complete the initial screening with patients prior to their visit.
3. Track patient TCM visits within 30 days of hospital discharge and plan.
Methods
Transitional care management screening was conducted via telephone in Medicare patients over the age of 65. If patients screened positive to being discharged within 14 days of the screening call, an in-office screening visit was scheduled with the provider. Following implementation of the project, patients were contacted to determine if they had visited an emergency room or been admitted to the hospital since screening.
Results
There was a total of 32 participants, ages 65 to 93 with a mean of 71.5. Of the total 32 participants, 17 were male (53.125%) and 15 were female (46.875%). Of the total 32 patients followed during the study, seven patients (21.875%) had been recently hospitalized within the past 14 days of being screened. The seven patients were seen in the office for an in-person TCM visit with the provider. By the end of the study, all seven patients have not been readmitted and none of the remaining 25 patients have been hospitalized.
Conclusion
It was shown that consistent transitional care management screening of Medicare patients can reduce hospital readmission. The goal of transitional care management is to improve community health and manage comorbid conditions closely while encouraging use of the primary care office for non-urgent acute visits to avoid hospital visits.
Creative Commons License
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Recommended Citation
Rosa, L.D. (2025). Using transitional care management screening tool on Medicare adult patients with chronic conditions: 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.