Date of Conferral

7-30-2026

Date of Award

July 2026

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Tracy Andrews

Abstract

Hospital readmissions remain a significant quality and patient safety concern across the United States, particularly among patients transitioning from rehabilitation settings to home or community-based care. Ineffective care transitions, fragmented communication, inconsistent discharge planning, and inadequate follow-up contribute to preventable hospital readmissions, increased healthcare costs, and poorer patient outcomes. Evidence consistently demonstrates that structured transitional care interventions and standardized care coordination processes improve continuity of care while reducing readmissions and enhancing patient satisfaction The purpose of this Doctor of Nursing Practice (DNP) project was to develop an evidence-based Clinical Practice Guideline (CPG) designed to improve post-rehabilitation discharge outcomes through implementation of a standardized care coordination bundle. The guideline was developed using the Johns Hopkins evidence-based practice model and evaluated through the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The practice-focused question guiding this project was: Will a CPG designed to support a care coordination bundle for improving post-rehabilitation discharge outcomes be approved by subject matter experts using the AGREE II Tool? Subject matter experts evaluated the guideline using the AGREE II Tool. Their feedback informed revisions that strengthened the guideline's clarity, applicability, feasibility, and evidence-based recommendations. Frontline end-user reviewers provided additional feedback regarding workflow integration and clinical usability. This guideline provides a practical roadmap aimed at improving transitional care processes and promoting safer, more effective patient-centered care.

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