Date of Award

Fall 2021

Project Type

Clinical Doctorate

College or School




Program or Major

Doctor of Nursing Practice

Degree Name


First Advisor

Diane E. Allen

Second Advisor

Angela Mackay


Readmission rates in hospitals across the country are at an all-time high. Patients being
discharged from the hospital may feel fearful, especially if they are experiencing a new onset of
illness. Many patients wonder how they will deal with or manage their illness once they return
home. The goal for hospitals should be to reduce readmissions by addressing the factors that
impact readmission. Improved care coordination is one of the goals of transitional care. Patients'
functioning and quality of life increase when hospital readmissions are reduced. Readmissions
can be reduced by addressing care management before and after discharge in all care settings.

The purpose of this quality improvement (QI) project was to implement transitional
interventions for patients in the psychiatric department to reduce rehospitalization rates. The
study's objectives were improved patient safety and health outcomes, ensuring that the transition
care program produces positive results. The QI project was implemented in an adult psychiatric
unit of an acute care hospital. The psychiatric unit has 37-beds, treating patients from different
walks of life and genders. The most common patient diagnoses include bipolar illness,
depression, anxiety, schizophrenia, and substance abuse disorders.

The project's goal was to have a transitional care protocol completely implemented with
the aim to reduce 30-day readmission rates by 20%. The transition care model (TCM) used
during the discharge process was intended to coordinate care and offer timely communication,
both of which are important in avoiding readmission. In the pre-implementation stage,
readmission rates were relatively high (75%). Following the implementation of this protocol, 80
patients in the post-implementation group were contacted for a follow-up call following their
recent discharge. After 30 days of follow-up, 13 patients had been readmitted back to the
inpatient psychiatry unit or other local units. In the pre-implementation group, there were 60 (75%) readmissions and 20 (25%) non-readmissions. In the post-implementation group, there
was a reduction in readmissions, 13 (16.3%). This reduction was statistically significant
highlighting the effectiveness of the TCM model.

TCM has also evidenced to minimize emergency department visits, rehospitalizations,
and hospital costs. TCM focuses on transitioning high-risk patients from the hospital to their
homes. TCM involves thorough assessment and planning before discharge, as well as home
follow-up. The transitional care model's efficacy was demonstrated by the findings of this
project. The proportion of readmissions decreased significantly from before to after the protocol
was implemented.