A Quality Improvement Initiative: A Nurse Practitioner-Led Interdisciplinary Approach to Reducing Readmissions in the Subacute Population

Abstract

BackgroundTo decrease the 30-day Subacute Readmissions in an outpatient facility by using an Advanced Practice Nurse (APN) Project Leader while applying evidence based transitional care processes.ObjectiveDetermine the effects of APN leadership within the Interdisciplinary Team in the subacute setting.MethodsImmersion of an APN as Project Leader over a 12-week period.ResultsOutcomes were divided into three groups. They were reorganized and analyzed. The new breakdown included patients readmitted plus hospice referrals (n = 5) and those not readmitted (n = 4). A significant difference in the 30-day outcomes as well as the LACE variable comorbidity scores t (4) = 2.95, p = 0.0418 were identified.ConclusionsThe 30-day readmission rates were decreased using hospice as a referral source. Application of the Lippitt’s Model of Planned Change and the use of the LACE Scoring Tool were instrumental to the success of this project.Implications for NursingTo improve optimal outcomes it is necessary for the APN/Doctor of Nursing Practice (DNP) and other healthcare professionals to engage in collaborative practices that result in effective policy changes. This quality improvement project restructured the existing Interdisciplinary Team processes to include the APN Project Leader with improved patient-centered outcomes.