Improving Care Transitions from Hospital to Home: Best Practice

Bumpas, Jerilyn W.
Stuart, Wilma Powell

Jerilyn W. Bumpas, DNP, MSN, RN, is Assistant Professor, School of Nursing, Tarleton State University, Stephenville, TX.
Wilma Powell Stuart, PhD, RN, NEA-BC, is Associate Professor, College of Nursing, University of South Alabama, Mobile, AL.

Acknowledgement: The authors would like to acknowledge Abigail Kendall, MSN, RN, CNO, Lake Granbury Medical Center, Granbury, TX.

MEDSURG Nursing 32(2):p 84-88, March-April 2023.

Literature Summary

Systematic problems in care transitions at discharge can lead to adverse events and contribute to preventable hospital readmissions (^;^;).
Several common problems leading to poor care transitions are related to communication, patient education, and accountability (^;).
Use of the Project RED Toolkit for patient discharge has been found to reduce 30-day readmission rates, improve patient experience, and lower healthcare costs ().

CQI Model

Plan-Do-Study-Act (PDSA) (AHRQ, 2015)

Quality Indicator with Operational Definitions & Data Collection Methods

The term transitions of care encompasses clinical handoff as well as clinical aspects of care transfer and other factors, such as the views, experiences, and needs of the patient (^;).
A short, informal, anonymous survey was given 2 weeks after project launch via text and the SurveyMonkey app to perform an in-progress assessment of learner (nursing staff) perceptions.

Clinical Setting

Two medical-surgical units (16 and 24 beds) within a 75-bed acute care facility in southwestern United States; average combined daily census 30 patients

Program Objective

Increase discharge care transition scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey by 10% in the care transitions domain for patients age 18 and older within 3 months.

Care transitions from hospital to home are a vulnerable exchange point for patients, contributing to high rates of patient safety adverse events that endanger the lives of patients and waste resources. Implementing a quality improvement project using proven Project RED (Re-engineered Discharge) components and the Always Use Teach-back Toolkit resulted in increased patient satisfaction scores in the transition-of-care domain.