Patients often experience challenges during the transition from one level of care to another, such as being discharged from the hospital to home. Issues like medication errors, lack of follow-up appointments, or inadequate understanding of post-hospital care instructions can negatively impact a patient’s health outcomes and risk readmission. For my capstone project, I developed and tested an intervention aimed at improving the transition of patients from the hospital to home setting.

First, I conducted a thorough literature review to understand the scope of the problem and identify evidence-based practices that have been shown to improve care transitions. Numerous studies have found that the lack of communication between providers during care transitions is a key factor contributing to poor outcomes. Interventions like improved discharge planning, medication reconciliation, and follow-up phone calls have demonstrated success in reducing readmission rates and improving patient satisfaction.

I then interviewed hospital care coordinators, primary care physicians, nurses, patients, and caregivers to gain insight into the specific challenges experienced locally. Common themes that emerged included a lack of shared treatment plans between hospitalists and primary providers, difficulty scheduling timely post-discharge follow-up appointments, medication discrepancies upon discharge, and inadequate education for patients and families on self-care needs and warning signs to watch out for after returning home.

Based on this needs assessment, I designed a multi-pronged intervention focused on enhancing communication and coordination between hospitals, primary care practices, and patients/caregivers. With input and approval from key stakeholders, I created a standardized discharge planning template and workflow. This included generating a comprehensive after-hospital care plan with treatment goals, follow-up needs, and instructions to share seamlessly between providers via the EHR. It also involved scheduling any necessary post-discharge appointments prior to leaving the hospital to allow timely follow-up.

Additionally, I developed a structured telephone-based program to support patients through the first 30 days post-discharge. Trained hospital nurses conducted phone calls 3, 7, 14, and 30 days after discharge to reinforce education, answer questions, reconcile medications, review symptoms and adherence, and identify any early signs of deterioration or potential readmission risks. Patients received an easy-to-understand checklist of critical information to manage their care transition. If issues arose, the nurses could facilitate prompt contact with primary care or other community resources.

To evaluate the effectiveness of this intervention, I conducted a quantitative pre-post analysis comparing outcomes for patients who received the new care transition supports versus usual care. With IRB approval and patient consent, I retrospectively reviewed hospital and primary care EHR data for 120 patients discharged 30 days prior to implementation and 120 patients who received the full intervention package within the first 30 days after the go-live date.

Key outcome measures included 30-day readmission rates, post-discharge emergency department visits, patient/caregiver understanding of discharge instructions, timeliness of follow-up appointments, accuracy of reconciled medication lists, and patient satisfaction scores. Statistical analysis revealed a 38% relative reduction in 30-day readmissions and a 56% decrease in ED visits within the first post-discharge month for patients exposed to the new transition of care supports compared to usual care patients. Post-discharge follow-up appointment adherence saw a 22% improvement and medication discrepancies dropped by 45% as well. Patient experience scores also increased significantly across multiple domains.

The results of this project provided strong evidence that a comprehensive approach addressing the major gaps identified in the care transition process can meaningfully impact important health outcomes like readmissions. I presented my findings to hospital administrators and primary care leadership who have since committed to spreading implementation of the standardized processes and supports developed across their full network. I believe this work demonstrates the potential for quality improvement partnerships between clinicians, health systems, and patients to build more cohesive and supportive care pathways during care transitions. With continuing effort, we can better equip patients and their families to successfully navigate transitions and prevent adverse events after hospitalization.

This capstone project addressed a prevalent problem in healthcare through conducting needs assessments, designing and testing multi-faceted evidence-based interventions, collecting and analyzing data to measure outcomes, and engaging key stakeholders. By enhancing communication, coordination, education and support for patients transferring between levels of care, significant improvements were seen in readmissions, emergency visits, medication management, appointment adherence and experience – representing more continuous, safe and reliable care across settings.