Date of Conferral

1-16-2025

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Mary Garner

Abstract

Timely follow-up care can avert patient readmission for older adults at risk of increased morbidities and mortalities. The target primary care clinic in the southwestern United States served a majority Hispanic population, whose readmission rates were higher than those of White or Black patients nationally. This quality-improvement (QI) project involved the evaluation of whether a new clinical practice guideline to require timely follow-up care was conducive to lowering patient readmission rates among Hispanic older adults 65 years of age and older. The practice-focused question concerned whether primary care providers’ use of a follow-up protocol within 7 days of discharge improved the quality of care and reduced readmission rates among older Hispanic patients. Before implementing the new protocol, an average of 13% of patients were readmitted over a 6-month period. Readmission cases to the hospital within 30 days of discharge postimplementation were significantly reduced to 5%. The chi-square value of 210.769 (df = 4, p < .001) confirms the protocol's effectiveness. The review of readmitted patients revealed a need for the refinement of clinical practice guidelines, particularly for patients with chronic conditions like congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), as well as those in the final stages of life. CHF and COPD patients had higher readmission rates despite transitional care. Evaluation of the transitional care protocol at this Southwest primary care clinic showed significant improvements in the management of hospital readmissions. The doctoral project established the importance of follow-up care for promoting positive social change, interprofessional collaboration, respect for diversity, health equity, and patient inclusion.

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