Fall 2023

Document Type

Scholarly Project


College of Nursing

First Advisor

Sevilla Bronson


Problem: Older adults recently discharged from a skilled nursing facility (SNF) (often referred to as short-stay facilities) experience a period of vulnerability while transitioning back into the community, placing them at increased risk of adverse events, including hospital readmissions (Anderson et al., 2021). Completing a timely appointment (within 7 days) with primary care providers following discharge into the community reduces patients’ risk of preventable hospital readmissions (RHI, 2023) through interventions aimed at promoting coordinated care and safe transitions (Patel et al., 2019). However, more than 50% of readmitted patients failed to visit a primary care provider's (PCP) office between SNF discharge to home and re-hospitalization (Aledade, 2022; Roper et al., 2017). Purpose: This DNP project aimed to decrease the re-hospitalization rate of residents who were discharged to home from Piedmont of Augusta’s skilled nursing facility, Westwood by improving coordination of care through pre-scheduled appointments integrated with new condition-specific discharge instructions. Method: The Donabedian Model for Quality of Care was used as the theoretical framework. PCP follow-up appointments were pre-scheduled within seven days of residents’ discharge and residents were provided condition-specific oral and written discharge instructions over a three-month period. Attendance to follow-up appointments as well as readmission rates to the hospital were monitored. Resident and staff satisfaction pertaining to the discharge process were obtained via surveys. Results: A total of 30 residents participated in this project, resulting in 100% agreement that the discharge packets were helpful. Of the 30 residents, six (20%) were readmitted to the hospital, 3 (13.6%) hospital readmissions occurred among the 22 residents who accepted pre-scheduled PCP appointments, and 3 of the 8 residents (37.5%) who did not accept pre-scheduled appointments were readmitted to the hospital. Implications for Practice: Pre-scheduling PCP appointments was described as valuable and effective by staff and residents and their family members with a marked reduction in hospital readmissions.


© 2023, Shantoria W Parker

Available for download on Sunday, June 30, 2024

Included in

Nursing Commons