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Implementing Post-Hospital Interprofessional Care Team Visits To Improve Transitions Of Care And Decrease Hospital Readmission Rates, Stacy M. Baldwin

Doctor of Nursing Practice (DNP) Final Clinical Projects, 2016-2019

Background: Today’s healthcare climate is comprised of a population of patients who are more complex, presenting with multiple comorbidities, and requiring frequent hospitalizations. It is imperative for acute care and primary care landscapes to bridge silos and form collaborative relationships to ensure safe and effective transitions of care from hospital to home. An interprofessional, post hospital follow-up clinic is one approach that can be utilized to improve transitions of care and decrease preventable hospital readmissions.

Purpose: The purpose of the project's discharge clinic was to improve transitions of care and decrease thirty day hospital readmission rates. The primary objective of …