Bridging the Gap Between Transitional Care and Home Health to Prevent Hospital Readmission

Abstract

Transitional Care (TC) aims to improve overall patient outcomes and promote continuity of treatment by coordinating healthcare for vulnerable groups. The DNP project aimed to facilitate care transitions using the Transitional Care Model (TCM). Patients at moderate to high risk of readmission were identified during their hospitalization and transitioned to outpatient treatment utilizing risk stratification techniques. The team’s primary duty was coordinating complicated care, including finding roadblocks to a patient’s therapy. Patient satisfaction increased due to increased patient engagement in their care, which was made possible by better coordination of services. There was also an improvement in team output and fewer hospital readmissions. The following steps will be to roll out the new procedure across the organization’s complete navigation team and evaluate the results thus far.