Date of Award

Spring 5-24-2019

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Kevin J. Maxwell DNP, FNP-BC, RN


Purpose/Aim:To determine whether a nurse practitioner-initiated phone call, in addition to the standard transition-of-care (TOC) protocol, will reduce 30-day hospital re-admissions by 50% in patients with end-stage renal disease (ESRD) after an inpatient index hospitalization.

Background: $27 billion is spent annually by Medicare for hospital readmissions. Approximately $17 billion of this amount can be attributed to avoidable causes (Kauffman, 2016). Hospitals have been penalized for excessive readmission rates under the Hospital Readmissions Reduction Program beginning in 2012 (HRRP; Centers for Medicare & Medicaid Services [CMS], n.d.). Index hospitalization refers to the first time, in a series of hospitalizations, that a patient is admitted for a specific condition or diagnosis. Medicare beneficiaries with ESRD, acute myocardial infarction, congestive heart failure, and pneumonia are the most common causes of readmissions.

In 2010, the Affordable Care Act (ACA) set aside $10 billion to encourage health care providers to develop a TOC program to reduce readmission rates (Kamermayer, Leasure, & Anderson, 2017). Several programs were developed and implemented, including HRRP and the Transition of Care Intervention Program under the ACA. In 2015, the Centers of Medicare and Medicaid Services introduced the Equity Plan for Improving Quality in Medicare (CMS, 2015). Telephone follow up calls have been shown to reduce 30-day readmission rates (Briscoe, 2018).

Process: Data from a hemodialysis clinic in southern California was /.p[;analyzed for patients with index hospitalizations. In addition to the clinic’s TOC follow-up protocol, an NP-initiated phone call three days post discharge will be made for customized counseling. Phone calls will be made every two weeks. Readmission rates will be monitored weekly and at 30 days. Data will be compared to the previous 12-month readmission rate (N = 31) prior to the addition of the nurse practitioner phone call.

Outcomes: The goal of this project is a 50% reduction in 30-day hospital readmissions (annual rate of 15 readmissions or less).

Conclusions: Prompt TOC with the addition of a nurse practitioner-initiated, follow-up phone call to patients with ESRD and with an index hospitalization will demonstrate a decrease in avoidable 30-day hospital readmission rates.

Included in

Nursing Commons