Implementing the Coordinated-Transitional Care Program

Implementing the Coordinated-Transitional Care Program

Implementing the Coordinated-Transitional Care Program 150 150 Peter

Implementing the Coordinated-Transitional Care Program

Review your problem or issue and the study materials to formulate a PICOT question for your capstone project change proposal. A PICOT question starts with a designated patient population in a particular clinical area and identifies clinical problems or issues that arise from clinical care. The intervention used to address the problem must be a nursing practice intervention. Include a comparison of the nursing intervention to a patient population not currently receiving the nursing intervention, and specify the timeframe needed to implement the change process. Formulate a PICOT question using the PICOT format (provided in the assigned readings) that addresses the clinical nursing problem.

The PICOT question will provide a framework for your capstone project change proposal.

In a paper clearly identify the clinical problem and how it can result in a positive patient outcome.

Describe the problem in the PICOT question as it relates to the following:

Evidence-based solution
Nursing intervention
Patient care
Health care agency
Nursing practice

NB: Problem: Reduction of Hospital Readmission Rates
Readmission of patients within 30 to 180 days of discharge is one of the hindrances to the provision of quality healthcare.

Sample Paper

PICOT Question

Population– Patients being discharged from healthcare settings

Intervention– Coordinated transitional care program

Comparison- Uncoordinated discharge process

Outcome- Reduced hospital readmission rates

Time- Thirty days

PICOT Question- For patients being discharged from healthcare settings, will a coordinated transitional care program, compared to an uncoordinated discharge process, reduce hospital readmission rates within thirty days?

Clinical Problem

The healthcare setting has been assigned penalties due to high readmission rates. The 30-day readmission rate in the hospital is about 10 patients out of 150 being discharged every month. This indicates a high readmission rate for a hospital with only 50 beds available. Hospital readmissions have been linked to high financial costs and unfavourable patient outcomes. Considerably, high readmission rates have reflected poor quality in health care services. McIlvennan, Eapen and Allen (2015) state that hospital readmissions are viewed as undesirable clinical outcomes since they suggest the patient has been prematurely discharged or that the post-hospitalization was suboptimal.

Evidence-Based Solution

Federman et al., (2018) conducted a case-control study on hospital-at-home patients with a concurrent group of inpatients from EDs in Newyork to examine the effectiveness of post-acute transitional care programs on patient experiences. The 30-day post-acute transitional care program was linked to improved patient outcomes. Morkisch et al., (2020) examined and summarized the transitional care model implemented among geriatric patients to determine its impact on reduced readmission rates. The study relied on articles that used randomized controlled trials with a sample of 50 and above participants and an intervention period of thirty days. Three articles were used to collect findings on the effectiveness of the transitional care model in reducing hospital readmission rates. The study findings demonstrated that transitional care models provide multidisciplinary interventions that effectively lower readmission rates without raising the care cost.

Nursing Intervention

To reduce hospital readmission rates, a coordinated transition care program will be an effective nursing intervention to improve and maintain the level of independence after discharge and in a non-hospital setting. The transition care program has a set of activities developed to guarantee continuity and harmonization of healthcare as the patient transfers between the hospital and non-hospital setting. According to Hirschman et al., (2015), comprehensive follow up and discharge planning interventions have reduced readmission rates among older people. Therefore, transitional care programs will effectively reduce unplanned hospital readmission rates.

Patient care

Hospital readmission has led to low-quality patient care. The readmission rates have been used to measure the need to improve quality care. There is a direct link between high-quality care and readmission rates. The quality of care can contribute to high or low readmission rates. Therefore, the transitional program will aim to improve the quality of patient care since it includes services and set guidelines that are used to ensure healthcare continuity. The transitional care program has effectively improved the quality of care since it helps in recovery by providing rehabilitative and nursing care, which is necessary to help the patient regain some degree of independence.

Healthcare Agency

Readmission rates are viewed as hospital quality measures and directly link to the cost of care. Healthcare agencies with high readmission rates are experiencing high expenditure on hospital resources since they spend more on readmissions (Upadhyay, Stephenson and Smith, 2019). Therefore, the transitional care program will reduce the readmission rates, thus lowering the operating revenues per patient. Healthcare agencies will experience low readmission rates, which will improve their quality indicators and drive in-stream of revenues.

Nursing Practice

Nursing practice is affected by the high rate of hospital readmissions as it makes nurses feel as if they fail to offer adequate transition care to the patient. The coordinated transitional care program will boost the nurse’s ability to support high-risk patients from the hospital’s settings to a non-hospital environment. Using the coordinated transitional program will enable the nurses to use set guidelines and protocols to provide transition care.



Federman, A. D., Soones, T., DeCherrie, L. V., Leff, B., & Siu, A. L. (2018). Association of a bundled hospital-at-home and 30-day post-acute transitional care program with clinical outcomes and patient experiences. JAMA internal medicine178(8), 1033-1040. Available at:

Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: the transitional care model. Online J Issues Nurs20(3). Available at:

McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation131(20), 1796-1803. Available at:

Morkisch, N., Upegui-Arango, L. D., Cardona, M. I., van den Heuvel, D., Rimmele, M., Sieber, C. C., & Freiberger, E. (2020). Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review. BMC geriatrics20(1), 1-18. Available at:

Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission rates and their impact on hospital financial performance: a study of Washington hospitals. INQUIRY: The Journal of Health Care Organization, Provision, and Financing56, 0046958019860386. Available at: