Document Type


Publication Date


Date of Final Presentation

Spring 3-8-2018

Committee Chair

Cara Gallegos, PhD, RN

Committee Member

Pam Strohfus, DNP, RN, CNE

Coordinator/ Chair of DNP Program

Pam Strohfus, DNP, RN, CNE

Abstract/ Executive Summary

Problem Description: Vulnerable, homebound older adults are highly susceptible to unplanned 30-day hospital readmissions, which is costly for the healthcare system. As a result, health care expenditures for this population continue to rise. Studies have shown that transition of care programs, when complemented with home-based primary care delivery, may improve health care outcomes for this population.

Purpose: The purpose of this quality improvement pilot project was to implement medical house calls as a component of transitional care management (TCM) and measure patient outcomes such as unplanned 30-day readmission rates and correlate predictors of readmission. As a secondary outcome, the project explored, tracked, and later analyzed point-of-care concerns during medical house call visits, which were conducted by a provider with prescriptive authority, a nurse practitioner (NP).

Interventions: Medicare beneficiaries, 65 years and older, who were discharged from skilled nursing facilities (SNFs) to home were identified by convenience sampling through referral and offered a home visit by an NP. Before discharge, patients’ acuity was assessed, and a LACE Index score was assigned. Unplanned 30-day readmissions to the hospital were measured and correlated to point-of-care conditions found during medical house call visits: number of days to see patients; common distribution of LACE Index scores; number of medications (polypharmacy) before and after visits; prescriptions required; comorbidities; and time to primary care provider (PCP) visits.

Results: A total of 145 patients were seen by the NP. LACE Index scores ranged from 11-15 (M = 12.6; SD = 2.9). The readmission rate was 19.2%, which was higher than the benchmark, 18.5%; however, the patients’ LACE Index scores indicated high acuity. Most patients experienced two comorbidities, with hypertension being the most common. Regression analysis showed that heart failure was a significant predictor of unplanned 30-day hospital readmissions. Heart failure patients were 5 times more likely to be readmitted than patients with other comorbidities. Medications were reduced after medication reconciliation from 17 to 11, which was statistically significant (z = -7.497, p < .001). Almost half of the patients required prescriptions during the visit, and more than half were unable to see their PCP for 14 days or more.

Interpretation: This project has shown that older adults discharged from a higher level of care can benefit from TCM through medical house calls by an NP within 14 days after discharge. Visits significantly reduced polypharmacy, provided a way to get prescriptions that would otherwise be unobtainable from a PCP for 14 days or more after discharge, and managed high readmission risks.

Conclusion: Further study of system redesign and policy change that affect care delivery by NPs in care transitions is highly recommended.