One example of a successful healthcare management capstone project analyzed strategies to improve care transitions from the hospital to home for elderly patients with congestive heart failure (CHF). Care transitions are a major healthcare issue as nearly 20% of Medicare patients are re-hospitalized within 30 days of being discharged, often due to failures in coordinating and continuing their care outside of the hospital setting. This can lead to poor health outcomes for patients as well as significant unnecessary costs for the healthcare system.

For this capstone project, the student conducted an extensive literature review on evidence-based care transition models and interviewed hospital administrators, case managers, physicians, home health nurses, and patients to understand the current process and pain points. The student found that while the local hospitals had some basic discharge planning and education in place for CHF patients, there was a lack of coordination with home health agencies and primary care providers. Patients reported being confused about what to do once at home to manage their conditions and who to contact if problems arose.

To address these gaps, the student proposed developing a formalized transitional care program for CHF patients that incorporated elements of successful care transition models. The key components of the program included:

Establishing a multidisciplinary transitional care team made up of an advanced practice nurse, social worker, and home health coordinator who would work together closely across care settings.

Implementing the “Teach Back” method for discharge education to reinforce patient/caregiver understanding of self-care needs and ensure they knew specific signs and symptoms to watch out for that may indicate a worsening of their condition.

Conducting a home visit by a nurse practitioner or home health nurse within 72 hours of discharge to evaluate how the patient was coping, review any early issues or Questions, and reinforce the discharge plan.

Utilizing transitional coaches – nursing or social work students – to provide weekly phone calls to patients for the first month after discharge to promote medication and appointment adherence as well as provide reassurance and a contact person if problems arose.

Developing electronic care plans accessible by all members of the care team to facilitate communication and coordination across settings.

Implementing standardized validated patient questionnaires at discharge, 30 days, and 90 days to evaluate health status and care experience as part of an outcomes tracking and program improvement process.

To test this transitional care model, the student partnered with one of the local hospitals, a home health agency, and a primary care clinic who served as the pilot site. Over 6 months, 30 CHF patients who consented were enrolled in the program. Quantitative and qualitative data was collected at various timepoints to analyze clinical outcomes like rehospitalization rates as well as patient/provider perceptions.

Preliminary results showed that at 30 days, only 10% of patients enrolled in the transitional care program had been rehospitalized compared to the national CHF 30-day rehospitalization average of 20%. Patient satisfaction surveys demonstrated high ratings for the level of preparation and support felt after discharge. Providers also reported improved communication and coordination of care.

Based on the successful initial pilot, the hospital, home health agency, and primary care clinic committed to expanding the transitional care program for CHF patients system-wide. The student worked with administrators to create a sustainable budget and staffing plan to implement the model on a larger scale. They also assisted in developing standard operating procedures and training materials. In the capstone paper, the student conducted a comprehensive discussion of the program impacts, lessons learned, and recommendations to evaluate and refine the model over time to further reduce rehospitalizations and improve patient outcomes and experiences.

This rigorous healthcare management capstone project tackled an important quality issue through developing an evidence-based intervention, piloting the program, collecting meaningful outcome data, and working to expand it into an ongoing initiative. The student demonstrated competencies in research, stakeholder engagement, program development, quality improvement methodology, and advocacy that are highly applicable to a career in healthcare administration. Their work serves as an excellent example of how a capstone can address a real-world problem and help optimize systems of care.