Gail Rattigan


Dunemn, Kathleen

Committee Member

Patterson, Marcia

Committee Member

Collins, Susan

Committee Member

Lamprecht, Scott


Nursing Practice


University of Northern Colorado

Type of Resources


Place of Publication

Greeley (Colo.)


University of Northern Colorado

Date Created



117 pages

Digital Origin

Born digital


Patients discharged from hospital to home, especially the chronically ill and older adults, are too frequently readmitted within 30 days. The Centers for Medicare and Medicaid Services (n.d.; 2017) along with other interdisciplinary researchers have proposed, studied, and implemented strategies to decrease this excessive and expensive phenomenon. After the implementation of the Hospital Readmission Reduction Program in 2009, preventable readmissions have decreased but remain at unacceptable levels. Care transitions from hospital to home have been implicated as perilous and fraught with communication breakdown and lack of patient support and follow up. Strategies aimed at both the hospitalization phase and the 30-day transitional phase when the patient returns home have been developed and implemented. This research translation project implemented a program of transitional care management in a community clinic in Las Vegas, Nevada in accordance of the guidelines of the transitional care model (TCM). Five patients were referred to the clinic by two home health agencies. The project coordinator provided transitional care for these patients for the duration of their home health certification. All of the patients were high risk for rehospitalization according to evidence-based screening tools. At the end of 30 days, none of the five patients had been rehospitalized. Additionally, two patients were referred from another medical practice and the project coordinator evaluated them through chart review and saw them once. The sample size and non-randomized sampling method precluded generalization of the findings. However, the project revealed important qualitative data relative to risks and interventions impacting rehospitalization risk as well as issues, barriers, and facilitators related to the practice of transitional care in the community setting. Several of these findings were not specifically identified within the TCM. Themes were derived from findings and a causal network was developed. Patients received excellent and effective transitional care and the project added to the body of knowledge of transitional care implementation.

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Copyright is held by the author.