Date of Award


Document Type


Degree Name

Doctor of Nursing Practice (DNP)


Nursing (Graduate)

First Advisor

Kristen Slabaugh


BACKGROUND: Unplanned hospital readmissions are a burden on healthcare expenditure. There is a paucity in research at the sub-acute level of care, where many patients receive services following a hospitalization, to decrease readmission rates. This project aimed to determine whether a formal transition of care program (TCP) in a sub-acute rehabilitation (SAR) center decreased unplanned hospital readmissions of adults within 30 days of discharge to home.

METHODS: A literature review identified evidence-based interventions used to develop a formal TCP in a SAR center. The Ottawa Model of Research Use was used for the quality improvement (QI) project. Data was collected over a 3-month implementation phase and 30-days following discharge to assess for statistically significant differences in readmission rates pre- and postintervention.

INTERVENTION: Participants were enrolled in a TCP that included plan of care meetings, treatment plan and disease-specific education, pharmacist-led medication reconciliation prior to rehabilitation discharge, scheduled home health, rehabilitation, and provider services after discharge, and follow-up communication with a team member weekly for a minimum of 30 days following discharge.

RESULTS: There was no statistically significant difference in hospital readmission rates between the pre- and postintervention groups.

CONCLUSIONS: A formal TCP at the SAR level of care may decrease 30-day unplanned readmission rates post-discharge. Future QI projects may be able to identify the impact of TCP at the SAR level of care with larger sample sizes.


Project and poster are included.