Abstract
Hospital readmissions from skilled nursing facilities (SNFs) contribute to poor patient outcomes, increased healthcare costs, and financial strain on healthcare systems. Older adults in SNFs are at increased risk for rehospitalization due to chronic illness, polypharmacy, and functional decline. The purpose of this quality improvement project was to implement a standardized high-risk screening checklist to improve identification of residents at risk for hospital readmission and reduce preventable 30-day readmissions among adults aged 65 years and older in a skilled nursing facility.
This project used a quasi-experimental pre- and post-implementation design without a control group and was guided by the Chronic Care Model. Baseline readmission data were collected for 60 days prior to implementation, followed by a 60-day post-implementation period during which the checklist was integrated into the admission process. Data were collected through review of electronic health records and transfer logs, and descriptive statistics were used to summarize findings.
During the pre-implementation phase, 22 residents were evaluated, with one hospital readmission occurring (4.5%). During the post-implementation phase, 16 residents were screened using the checklist, with one hospital readmission observed (6.3%). Although readmission rates did not decrease during the project period, the intervention improved identification of residents at elevated risk for rehospitalization and promoted a more standardized approach to care planning. Findings support the feasibility of incorporating a readmission risk checklist into routine SNF workflows and suggest potential for future improvement in transitional care and readmission prevention.
Sigma Membership
Non-member
Type
DNP Capstone Project
Format Type
Text-based Document
Study Design/Type
Quality Improvement
Research Approach
Pilot/Exploratory Study
Keywords:
Skilled Nursing Facility, Nursing Care Facilities, Hospital Readmissions, Patient Readmissions, Risk Screening Checklist, Health Risk Assessment, Older Adults, Older People, Transitional Care
Advisor
Valerie Anderson
Degree
DNP
Degree Grantor
Nebraska Methodist College
Degree Year
2026
Recommended Citation
Williamson, Kayla G., "Implementing a High-Risk Screening Checklist to Reduce 30-day Readmissions in Skilled Nursing Facility Residents" (2026). Group: Nebraska Methodist College. 116.
https://www.sigmarepository.org/group_nmc/116
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
Self-submission
Date of Issue
2026-10-15
Full Text of Presentation
wf_yes
Description
NRS 890 Doctoral Scholarly Project
This project used a quasi-experimental pre- and post-implementation design without a control group and was guided by the Chronic Care Model.