Date of Award

Spring 2025

Project Type

Clinical Doctorate

College or School

CHHS

Department

Nursing

Program or Major

DNP

Degree Name

Other

First Advisor

April Phelps

Abstract

BACKGROUND: Transitions in care from hospitalization to home are a high-risk period for patients. Without care coordination during these transitions in care, patients are left trying to manage their care without any support. The VA has a mandated two-day post-discharge contact process that requires a member of the patient’s primary care team to contact the patient within two business days of a VA discharge.

METHODS: The Plan-Do-Study-Act method of quality improvement was used for this project. Baseline assessment included review of patient medical records for 15 months before the intervention, which included 27 discharges from unit 78C. The patient medical records were assessed for compliance with factors associated with the two-day post-discharge contact process.

INTERVENTIONS: The project included the primary intervention of educating the Home-Based Primary Care (HBPC) RNs on the two-day post-discharge contact process and the associated required documentation. Supportive interventions included training the HBPC Advanced Medical Support Assistant (AMSA) on providing Daily Discharge Report handoffs and collaborating with the 78C lead provider on completing discharge handoffs.

RESULTS: The two-day post-discharge contact compliance rate increased from 37% (10/1/2023 – 12/31/2024 average) to 80% (2/20/2025 – 4/15/2025); however, this compliance rate only included five discharges within the post-intervention timeframe.

CONCLUSIONS: This project was completed on a smaller scale than initially intended, yet it was still a useful project and helped set the stage for the project to be completed on a larger scale.

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