Date of Project Completion

Fall 11-1-2021

Document Type

Project Paper

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Jennifer Prochnow, DNP

Second Advisor

Kimberly Langer, DNP

Location

Rochester, MN

Abstract

Purpose and Rationale: The purpose of this project is to improve a post-discharge follow-up phone call program by creating evidence-based methods of collecting, documenting, and analyzing data that will provide insight of the program’s impact on patient and process outcomes. There was sufficient evidence to support the use of follow-up phone calls as an effective method to limit hospital readmissions within thirty days of being discharged. The literature also revealed patient and process outcomes to be measured as a final step in the program and to provide data for ongoing process improvement. Practice Change and Implementation Strategies: The current phone call program, such as timing and provider/nurse script, was aligned with the most recent evidence but lacked data collection and evaluation. The project will focus on creating algorithms that will improve decision-making and actions to take after follow-up phone calls are complete, refining methods for collecting data, and evaluating patient and process outcomes. Evaluation: Process outcomes include completion rates of follow-up phone calls and categorized discrepancies recorded during follow-up, allowing for future changes to be implemented to enhance the discharge process. Patient outcomes include 30-day readmissions. Conclusion and Implications for Practice: Adequate data collection will allow for analysis of processes and patient outcomes. The importance of the program and data collection relates to identifying gaps in patient care and education during discharge from the hospital, as well as targeting patient outcomes such as decreased readmission to the hospital within 30 days.

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