Implementing Risk Tools to Prevent Hospital Readmission
Tara O’Connor
Abstract
Background: Readmission reduction is one of the most important opportunities for reducing cost in today’s health care system.
Global Aim: To operationalize risk tools to reduce hospital readmissions by 5 percent by the end of 2017.
Project Aim: To develop new transitions program (TP) processes that operationalizes the risk tools and ensures 70 percent of all readmission risk score patients referred receive a post discharge phone call within 48 hours, and are assessed for their risk of medication management issues as part of their initial assessment, by August 1st, 2017.
Setting: The TP provides short term case management for patients transitioning home from hospital and other level of care.
Quality Gap: An evidence-based means of identifying patients at risk for readmission and a standardized process for assessing medication management issues was previously lacking.
Evidence: Intervention demonstrated in clinical trial to reduce readmissions requires timely post discharge follow-up, assessment of and interventions for medication management issues, education on the plan of care, and interventions that address the social barriers of health maintenance and promote patients’ and their caregivers’ capacity for self-management.
Results: Through clinical leadership, utilization of the Institute for Healthcare Improvement’s (IHIs) model for improvement, and interdisciplinary collaboration, the TP team has developed new processes that preliminary data suggests are accomplishing the project aim.
","abstract_html":"<p>Implementing Risk Tools to Prevent Hospital Readmission</p> <p>Tara O’Connor</p> <p>Abstract</p> <p><strong>Background: </strong>Readmission reduction is one of the most important opportunities for reducing cost in today’s health care system.</p> <p><strong>Global Aim:</strong> To operationalize risk tools to reduce hospital readmissions by 5 percent by the end of 2017.</p> <p><strong>Project Aim:</strong> To develop new transitions program (TP) processes that operationalizes the risk tools and ensures 70 percent of all readmission risk score patients referred receive a post discharge phone call within 48 hours, and are assessed for their risk of medication management issues as part of their initial assessment, by August 1<sup>st,</sup> 2017.</p> <p><strong>Setting</strong>: The TP provides short term case management for patients transitioning home from hospital and other level of care.</p> <p><strong>Quality Gap:</strong> An evidence-based means of identifying patients at risk for readmission and a standardized process for assessing medication management issues was previously lacking.</p> <p><strong>Evidence:</strong> Intervention demonstrated in clinical trial to reduce readmissions requires timely post discharge follow-up, assessment of and interventions for medication management issues, education on the plan of care, and interventions that address the social barriers of health maintenance and promote patients’ and their caregivers’ capacity for self-management.</p> <p><strong>Results:</strong> Through clinical leadership, utilization of the Institute for Healthcare Improvement’s (IHIs) model for improvement, and interdisciplinary collaboration, the TP team has developed new processes that preliminary data suggests are accomplishing the project aim.</p>","abstract_has_math":false,"creators":["O'Connor, Tara"],"institution":null,"degree_name":"Master of Science in Nursing (MSN)","degree_level":"Project/Capstone - Global access","degree_discipline":null,"degree_department":null,"school":null,"contributors":["Dr. Nancy Taquino"],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2017,"date_issued":"2017-08-09T07:00:00Z","date_published":"2017-08-09T07:00:00Z","updated_at":"2026-07-24T05:44:00Z","subjects":["readmission prevention","transitional care","care coordination","medication management","readmission risk","Other Nursing"],"languages":[],"rights":[],"rights_urls":[],"identifier_entries":[]},"links":{"outbound_url":"https://repository.usfca.edu/capstone/581","outbound_label":"Repository record","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor","label":"Contributor","values":["Dr. Nancy Taquino"]},{"key":"dc:creator","label":"Author","values":["O'Connor, Tara"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date.available","label":"Dc Date Available","values":["2017-08-06T07:00:00Z"]},{"key":"thesis:degree_level","label":"Degree Level","values":["Project/Capstone - Global access"]},{"key":"thesis:degree_name","label":"Degree Name","values":["Master of Science in Nursing (MSN)"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["readmission prevention","transitional care","care coordination","medication management","readmission risk","Other Nursing"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://repository.usfca.edu/capstone/581"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description.abstract","label":"Abstract","values":["Implementing Risk Tools to Prevent Hospital Readmission
Tara O’Connor
Abstract
Background: Readmission reduction is one of the most important opportunities for reducing cost in today’s health care system.
Global Aim: To operationalize risk tools to reduce hospital readmissions by 5 percent by the end of 2017.
Project Aim: To develop new transitions program (TP) processes that operationalizes the risk tools and ensures 70 percent of all readmission risk score patients referred receive a post discharge phone call within 48 hours, and are assessed for their risk of medication management issues as part of their initial assessment, by August 1st, 2017.
Setting: The TP provides short term case management for patients transitioning home from hospital and other level of care.
Quality Gap: An evidence-based means of identifying patients at risk for readmission and a standardized process for assessing medication management issues was previously lacking.
Evidence: Intervention demonstrated in clinical trial to reduce readmissions requires timely post discharge follow-up, assessment of and interventions for medication management issues, education on the plan of care, and interventions that address the social barriers of health maintenance and promote patients’ and their caregivers’ capacity for self-management.
Results: Through clinical leadership, utilization of the Institute for Healthcare Improvement’s (IHIs) model for improvement, and interdisciplinary collaboration, the TP team has developed new processes that preliminary data suggests are accomplishing the project aim.
"]},{"key":"dc:title","label":"Title","values":["Implementing Risk Tools to Prevent Hospital Readmission"]}]}],"canonical_facts":{"dc:contributor":["Dr. Nancy Taquino"],"dc:creator":["O'Connor, Tara"],"dc:date.available":["2017-08-06T07:00:00Z"],"dc:description.abstract":["Implementing Risk Tools to Prevent Hospital Readmission
Tara O’Connor
Abstract
Background: Readmission reduction is one of the most important opportunities for reducing cost in today’s health care system.
Global Aim: To operationalize risk tools to reduce hospital readmissions by 5 percent by the end of 2017.
Project Aim: To develop new transitions program (TP) processes that operationalizes the risk tools and ensures 70 percent of all readmission risk score patients referred receive a post discharge phone call within 48 hours, and are assessed for their risk of medication management issues as part of their initial assessment, by August 1st, 2017.
Setting: The TP provides short term case management for patients transitioning home from hospital and other level of care.
Quality Gap: An evidence-based means of identifying patients at risk for readmission and a standardized process for assessing medication management issues was previously lacking.
Evidence: Intervention demonstrated in clinical trial to reduce readmissions requires timely post discharge follow-up, assessment of and interventions for medication management issues, education on the plan of care, and interventions that address the social barriers of health maintenance and promote patients’ and their caregivers’ capacity for self-management.
Results: Through clinical leadership, utilization of the Institute for Healthcare Improvement’s (IHIs) model for improvement, and interdisciplinary collaboration, the TP team has developed new processes that preliminary data suggests are accomplishing the project aim.
"],"dc:identifier":["https://repository.usfca.edu/capstone/581"],"dc:subject":["readmission prevention","transitional care","care coordination","medication management","readmission risk","Other Nursing"],"dc:title":["Implementing Risk Tools to Prevent Hospital Readmission"],"thesis:degree_level":["Project/Capstone - Global access"],"thesis:degree_name":["Master of Science in Nursing (MSN)"]},"updated_at":"2026-07-24T05:44:00Z"}