Document Type


Publication Date


Date of Final Presentation


Committee Chair

Jane Grassley, PhD, RN, IBCLC

Committee Member

Kim Martz, PhD, RN

Coordinator/ Chair of DNP Program

Pamela Strohfus, DNP, RN, CNE

Abstract/ Executive Summary

Background: A major national-to-local healthcare quality and safety goal is to reduce hospital readmissions, which are considered preventable patient harm. While the literature shows the impact of using care transitions programs to reduce readmissions, few studies have utilized faith community nurses (FCNs) within care transition programs. An FCN-integrated care transitions program potentially could help fill the gap in community clinical support for chronic illness care. Saint Alphonsus Regional Medical Center (SARMC), a Catholic hospital in Boise, Idaho, sponsors an FCN network within many Southwest Idaho faith communities. This presented a local opportunity to create and test the feasibility of an FCN-integrated care transition pathway, using an evidence-based practice model such as the Care Transitions Intervention (CTI), to impact patient experience and outcomes post-discharge. The purpose of this project was to evaluate the feasibility of using FCNs as hospital CTI Transition Coaches and illuminate facilitators and barriers to their work.

Methods: Three FCNs trained to intervene with a targeted group of orthopedic patients, using the CTI model and protocol resources for Care Transitions Coaches, which included a 30-day patient engagement of a hospital contact, a home visit, and three phone calls. Primary outcomes were to implement an FCN-integrated CTI program, to evaluate both the effectiveness and satisfaction of the FCNs as Transition Coaches, and to quantify adequacy of the hospital support in fulfilling the CTI work and give voice to the facilitators and barriers to FCN-CTI care delivery.

Results: Feasibility evaluation was determined by if the CTI model could be implemented using FCNs. Over the time period of August 2015 to January, 2016, 24 patients, aged 65 and older, having total hip or knee surgeries, were enrolled as participants in the project. The FCNs completed the 30-day CTI follow-up protocol with 18 patients (75%) with 100% of the protocol documentation completed (18/18 checklist forms), 100% protocol visits accomplished (90/90), and 100% of Patient Activation Assessments were performed (72/72). FCNs reported 99% of the time (71/72 assessment visits) having the resources needed for Coaching. Key facilitators for effective Coaching included a project coordinator to help the FCNs navigate the hospital system and effective communication strategies with staff and providers. Barriers highlighted by the FCNs included poor usability of the personal health record tool, confusing discharge instructions, and challenges with coordinating hospital visits before discharge. The FCNs appeared satisfied that the Transition Coach role falls within FCN scope and standards of practice. They also found the stipend to be a beneficial incentive.

Conclusions: Healthcare delivery is transforming from hospital-focused care to community-based care. Providing care transitions resources to ensure healing after hospital discharge and prevent unnecessary readmissions benefits patients and hospitals. This project demonstrated that FCNs can be effective Transition Coaches and successfully implement the CTI model. Although often in unpaid roles in faith communities, the FCNs in this project were remunerated with a stipend. FCNs performing care transitions should be compensated for this value-based work, a trend that will likely be more common as reimbursement for care transitions grows in payer practices.