Date of Degree


Document Type

Doctoral Project

Degree Name

Doctor of Nursing Practice (DNP)




Holly A. DiLeo


Guillermo Rocha


Communication breakdown happens between transitions of care because healthcare disciplines function as silos. Medication and treatment plan changes are not always communicated to the next healthcare provider resulting in fractured care and preventable unnecessary cost. The purpose of this project was to create a standardized transition of care process from the acute care setting to the primary care setting in adult patients using evidence-based practice. The objectives of the project were the following: (1) to have a follow-up appointment within 14 days of discharge from an acute care setting, (2) to have a medication reconciliation performed and documented by the physician at the postdischarge follow-up visit, (3) to have a discharge summary verified by the physician at the postdischarge follow-up visit, and (4) to reduce 30-day hospital and emergency department readmissions by 25%. Planned interventions included staff education of transition of care process, acute care data collection, and patient follow-up. Evaluation plans included review of the electronic health record and hospital queries comparing pre- and postintervention data. Results showed a 24% increase in postdischarge follow-up appointments within 14 days, an average of a 26% increase in transition of care communication, and a 7% decrease in emergency room readmissions. Hospital readmissions increased by 7%. Implications for the practice include standardizing the process for all transitions of care, streamlining access to transition of care data, and having one affordable and user-friendly central database available to primary care practices.