Date of Conferral

11-25-2025

Date of Award

November 2025

Degree

Doctor of Healthcare Administration (D.H.A.)

School

Management

Advisor

Donna Clews

Abstract

Hospital readmissions within 30 days for acute myocardial infarction, congestive heart failure, and pneumonia remain a major challenge. These readmissions increase costs, worsen patient outcomes, and trigger penalties under the Hospital Readmission Reduction Program. The purpose of this integrative review was to identify evidence-based administrative strategies that could reduce 30-day readmission rates to 11.9% or lower, aligning with California’s statewide targets. The key review question explored which best practices most effectively lower readmissions in these patients. Wagner’s Chronic Care Model is a conceptual framework that enhances chronic illness care by integrating six interrelated components. Guided by this framework, a systematic literature search was conducted across multiple databases for peer-reviewed studies published between 2019 and 2024. A total of 26 articles were appraised using the Johns Hopkins Evidence-Based Practice Model, and 21 high- or good-quality studies were included. Four themes emerged as central to reducing readmissions: healthcare organization and leadership, clinical information systems, transitional care, and self-management support. The review also identified 21 subthemes. The most impactful were patient education, multidisciplinary governance, discharge planning, post-discharge follow-up, and addressing social determinants of health. Reducing readmissions requires multifaceted, system-level strategies reinforced by leadership, patient engagement, and coordinated transitional care. Hospitals that integrate these evidence-based practices with technology and community partnerships are best positioned to improve outcomes. Positive social change may result from advancing health equity by reducing preventable readmissions, addressing social determinants, and improving care continuity for high-risk populations.

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