Document Type


Publication Date


Date of Final Presentation


Committee Chair

Dr. Sarah Ahten, DNP, RN

Committee Member

Dr. Teresa Serratt, PhD, RN

Coordinator/ Chair of DNP Program

Dr. Pamela Gehrke

Abstract/ Executive Summary

Problem Description: The importance of management of chronic disease and preventing rehospitalization has been identified at national and local levels. Chronic obstructive pulmonary disease (COPD) is one of the chronic diseases with notable rates of emergency department use and recurrence of hospitalizations.

Rationale: Implementation of transitional care models have been successful for health care organizations in chronic disease management.

Interventions: The health-social partnership transitional care management program (HSTCMP) was used to design a transitional care model process pilot for a home health agency (HHA) within a health system. This process used a multidisciplinary team led by a registered nurse for older adult patients with COPD.

Results: The staff of the HHA demonstrated increased knowledge of transitional care and implemented the transitional care process for 35% of COPD patients. The agency identified the process components that worked well and areas needing further development.

Summary: Barriers were identified in the process pilot implementation including lack of knowledge on accessing members of the multidisciplinary team, vacancies in positions of key players, and previously unknown issues with the electronic health record.

Conclusion: The selected transitional care model provided a standardized, evidence-based model for the HHA. The process required revisions to work more efficiently since the identification of barriers. The agency would benefit from a second implementation of the process with the identified revisions.