Date of Award

Spring 2022

Project Type

Clinical Doctorate

College or School




Program or Major

Doctor of Nursing Practice

Degree Name


First Advisor

Dr. DiNapoli

Second Advisor

Dr. Beliveau

Third Advisor

Dr. Colleran


Reimbursement for home-based care is moving towards a value-based purchasing (VBP) model. This change brings a renewed sense of urgency to focus efforts in care delivery to sustain positive outcomes such as reducing rehospitalizations. The Clinical Nurse Leader role has been instrumental in hospital settings in improving patient outcomes, and evidence points toward the potential success of implementation of this role in the rural microsystem setting. This quality improvement project implemented a remote telehealth intervention led by Clinical Nurse Leaders, to decrease rehospitalizations of Medicare patients assessed as at-risk for 30-day rehospitalization. The DMAIC QI model was used to ensure sustained quality improvement. Methodology included a cohort study model with one cohort receiving the intervention of CNL telehealth calls following admission to Home Health over an 8-week time frame. The measure of this QI project included the comparison of the rate of rehospitalization between the cohorts. Analysis includes rehospitalization rate analysis, as well as qualitative themes derived from interventions taken by the CNLs during the intervention cohort. Results showed a slight increase in rate of rehospitalization for 30-days, yet a drastic decrease of rehospitalization rates in the intervention cohort for 60-day rehospitalizations. CNL interventions included themes of patient and caregiver education, care coordination and connecting to social work/community resources. A cost savings for the 60-day prevention of rehospitalizations for the intervention cohort was calculated at $187,900. Long term prevention of hospitalizations has large cost savings impact for health systems, CMS, but most importantly on the quality of life of patients, and the CNL role through telehealth is prepared to address this need.