Abstract

Vulnerable, homebound older adults are highly susceptible to unplanned 30-day hospital readmissions, which is costly for the healthcare system. As a result, health care expenditures for this population continue to rise. Studies have shown that transition of care programs, when complemented with home-based primary care delivery, may improve health care outcomes for this population.

The purpose of this quality improvement pilot project was to implement medical house calls as a component of transitional care management (TCM) and measure patient outcomes such as unplanned 30-day readmission rates and correlate predictors of readmission. As a secondary outcome, the project explored, tracked, and later analyzed point-of-care concerns during medical house call visits, which were conducted by a provider with prescriptive authority, a nurse practitioner (NP).

Author Details

Ron Billano Ordona, DNP, FNP-BC, GS-C, WCC

Sigma Membership

Mu Gamma at-Large

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Quality Improvement

Research Approach

Pilot/Exploratory Study; Translational Research/Evidence-based Practice

Keywords:

Elderly, Hospital Readmissions, Transitional Care Management

Advisor

Cara Gallegos

Second Advisor

Pam Strohfus

Degree

DNP

Degree Grantor

Boise State University

Degree Year

2018

Rights Holder

All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.

All permission requests should be directed accordingly and not to the Sigma Repository.

All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.

Review Type

None: Degree-based Submission

Acquisition

Proxy-submission

Date of Issue

2024-04-08

Full Text of Presentation

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