Abstract

Background: Thirty-day hospital readmissions compromise patient safety, increase mortality risk, and impose financial penalties on hospitals. Ineffective discharge education and care transitions leave patients vulnerable after discharge. Evidence shows that post-discharge follow-up calls within 24–72 hours can identify risks early and reduce preventable readmissions.

Purpose: This Doctor of Nursing Practice (DNP) project aimed to reduce 30-day hospital readmission rates by implementing post-discharge follow-up telephone calls guided by the Agency for Healthcare Research and Quality (AHRQ) Re-Engineered Discharge (RED) Toolkit.

Methods: Registered nurses conducted structured follow-up calls within 24–72 hours of discharge from the medical-surgical unit, reviewing health status, medications, appointments, and home care needs. Pre- and post-intervention data were collected from the electronic medical record and analyzed using descriptive statistics and a Chi-square test.

Results: Among 287 patients receiving standard care, the 30-day readmission rate was 17%. Following the intervention, the rate decreased to 3.5% among 112 patients who received follow-up calls, representing a 13% absolute reduction (χ² = 12.05, p = 0.0005).

Conclusions: Post-discharge follow-up calls, guided by the RED Toolkit, significantly reduce 30-day readmissions while improving patient safety, satisfaction, and organizational performance. Findings support the integration of nurse-led, evidence-based interventions into routine discharge planning to strengthen care transitions across healthcare settings.

Author Details

Maureen R. Wright, DNP, EMBA, MS, BSN, RN

Sigma Membership

Psi Tau Chapter

Type

DNP Capstone Project

Format Type

Text-based Document

Study Design/Type

Quality Improvement

Research Approach

Translational Research/Evidence-based Practice

Keywords:

30-Day Readmission Reduction, Post-Discharge Telephone Follow-Up, Re-Engineered Discharge (Red) Toolkit

Advisor

Beth Marquez

Second Advisor

Rebecca Toothaker

Degree

DNP

Degree Grantor

Chamberlain University

Degree Year

2024

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.

Review Type

None: Degree-based Submission

Acquisition

Self-submission

Full Text of Presentation

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Available for download on Friday, September 04, 2026

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