Date of Award

Spring 5-23-2020

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Karen Sue Hoyt, Phd, RN, FNP-BC, ENP-C, FAEN, FAANP, FAAN

Abstract

Abstract

Background: Poorly coordinated care often results in poor health outcomes. Best practices in academic literature recommend effective programs that consist of comprehensive discharge planning, complete and timely communication of information, medication reconciliation, patient and caregiver education using the teach-back method, open communication among providers, and prompt follow-up visits with an outpatient provider after discharge. Using a priority care clinic (PCC) for follow-up is one approach to decrease hospital readmissions.

Purpose: To implement an evidence-based program utilizing a PCC to facilitate post-discharge transition-in-care and reduce hospital readmissions.

Evidence-based Intervention: A PCC assists patients in their transition of care from the hospital to home. Delays in follow-up appointments and lapse in medication adherence may occur between hospital discharge and the first follow-up visit, thus resulting in unnecessary hospital readmissions.

Evaluation/Results: Data will be retrospectively collected and reviewed from patients’ charts to assess for compliance with (a) follow-up visit appointment, (b) medication adherence, and (c) readmission rates using a nurse practitioner-led a follow-up phone call and comparing results to the national benchmark.

Implication for Practice: PCCs are the necessary bridge to facilitate increased compliance with prompt follow-up visits and medication reconciliation to ensure adherence.

Conclusion: Implementation of a PCC addresses the need for reducing avoidable readmissions and complying with reimbursement standards required by the Centers for Medicare and Medicaid Services while meeting the best practice needs for patients.

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