Implementing the Coordinated-Transitional Care Program to reduce cause of readmissions

Implementing the Coordinated-Transitional Care Program to reduce cause of readmissions

Implementing the Coordinated-Transitional Care Program to reduce cause of readmissions 150 150 Peter

Implementing the Coordinated-Transitional Care Program to reduce cause of readmissions

While the implementation plan prepares students to apply their research to the problem or issue they have identified for their capstone project change proposal, the literature review enables students to map out and move into the active planning and development stages of the project.

A literature review analyzes how current research supports the PICOT, as well as identifies what is known and what is not known in the evidence. Students will use the information from the earlier PICOT Question Paper and Literature Evaluation Table assignments to develop a word review that includes the following sections:

1-Title page
2-Introduction section
3-A comparison of research questions
4-A comparison of sample populations
5-A comparison of the limitations of the study
6-A conclusion section, incorporating recommendations for further research

NB: I am sending the files for PICOT Question Paper and Literature Evaluation Table assignments. They were already done.

Sample Paper

Implementing the Coordinated-Transitional Care Program

Hospital readmissions are a major issue in most healthcare facilities, and they are linked to several poor health outcomes for the patients and higher financial expenditure. Among the interventions that have been proposed to reduce hospital readmission rates include transitional care programs following discharge from a healthcare facility. Several research studies have shown that these programs can effectively reduce readmission rates and improve patient outcomes. This paper will compare different articles that evaluated the effectiveness of transitional care programs following discharge from hospitals.

A Comparison of Research Questions

            The researchers in the different articles examined the effectiveness of coordinated transitional care programs once a patient was discharged from the healthcare facility. However, research questions were different; Acher et al. (2017) research questions included the feasibility and preliminary effectiveness of a coordinated transitional care program among patients who had undergone surgical procedures? Chapman et al. (2018) what is the role of physicians and nurses in educating residents on transitional discharge education. Driver et al. (2021) evaluated whether the C-TraC program can provide sustainable care for non-chronic illnesses. Leonard et al. (2017) evaluated what would be the best way to implement and adapt a TNP for veteran centres in rural areas. Reese et al. (2019) assessed how to effectively adapt C-TraC in meeting the needs of patients with CHF and COPD? While Takchi et al. (2020), what are the patient outcomes following an expedited discharge after enhanced recovery after surgery (ERAS) pathway. 

A Comparison of Sample Populations

Acher et al. (2017) included 212 patients who had undergone surgical procedures such as gastrectomy and pancreatectomy. The mean age was 56 years, and the range was 19-87 years. Chapman et al. (2018) included 87 trainees in the residency program. 31 had VA-based primary care clinics, while the remaining 56 interacted with the patients in university-affiliated clinics. Driver et al. (2021) enrolled 120 veterans with COVID 19, and 70% had a medical condition associated with poor COVID 19 outcomes. Leonard et al. (2017) study was a program evaluation and not a human research study; therefore, no human participants were included. Reese et al. (2019) enrolled 229 veterans on the study. Takchi et al. (2020) included 90 patients, the mean age was 66.3 years, and 58.1% were males.

A Comparison of the Limitations of the Study

All the studies had some limitations. In the study by Acher, 15% of the participants failed to use the follow-up contact without any explanation, limiting the caregivers’ ability to encourage the patients for future participation in such programs. The study by Chapman was preliminary and therefore did not determine the impact on transition care and patient outcomes. The study by Driver did not include a diverse population since only veterans, and mostly males were included, and therefore, the results cannot be generalized to other populations. Leonard’s study did not provide barriers encountered in implementing such programs nor interventions that can be used to overcome such barriers. Reese et al. (2019) only included patients with CHF and COPD, and therefore the results are not generalizable to other patients. Similar to Reese’s study, the study by Takchi also failed to include diversity in their research, limiting the generalizability of the results achieved.


The different studies found that transitional care programs can effectively improve patient outcomes following discharge from healthcare facilities and can also effectively contribute to decreased hospital readmissions. Reese et al. (2019) found that with the C-TraC, the patients were 54% less likely to be readmitted, and the total cost of care after discharge decreased by $1842.52. Therefore, C-TraC is effective and should be implemented to decrease hospital readmission rates and other poor patient outcomes.


Acher, A. W., Campbell-Flohr, S. A., Brenny-Fitzpatrick, M., Leahy-Gross, K. M., Fernandes-Taylor, S., Fisher, A. V., … & Weber, S. M. (2017). Improving patient-centered transitional care after complex abdominal surgery. Journal of the American College of Surgeons225(2), 259-265.

Chapman, E., Eastman, A., Gilmore-Bykovskyi, A., Vogelman, B., & Kind, A. J. (2018). Development and preliminary evaluation of the resident coordinated-transitional care (RC-TraC) program: A sustainable option for transitional care education. Gerontology & geriatrics education39(2), 160-169.

Driver, J. A., Strymish, J., Clement, S., Hayes, B., Craig, K., Cervera, A., … & Fantes, T. (2021). Front‐Line innovation: Rapid implementation of a nurse‐driven protocol for care of outpatients with COVID‐19. Journal of clinical nursing30(11-12), 1564-1572.

Leonard, C., Lawrence, E., McCreight, M., Lippmann, B., Kelley, L., Mayberry, A., … & Burke, R. (2017). Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study. Implementation Science12(1), 1-8.

Reese, R. L., Clement, S. A., Syeda, S., Hawley, C. E., Gosian, J. S., Cai, S., … & Driver, J. A. (2019). Coordinated‐transitional care for veterans with heart failure and chronic lung disease. Journal of the American Geriatrics Society67(7), 1502-1507.

Takchi, R., Williams, G. A., Brauer, D., Stoentcheva, T., Wolf, C., Van Anne, B., … & Hawkins, W. G. (2020). Extending enhanced recovery after surgery protocols to the post-discharge setting: a phone call intervention to support patients after expedited discharge after pancreaticoduodenectomy. The American Surgeon86(1), 42-48.