Date of Award


Document Type


Degree Name

Doctor of Nursing Practice

Degree Discipline

Nursing Practice


Hospital readmissions cost the U.S. healthcare system approximately $17.4 billion each year. Minimizing hospitalizations among Medicare beneficiaries is therefore a high priority. This study aimed to evaluate how identifying patients at high risk of hospital readmission—i.e., patients with complex health needs, such as those with chronic conditions—and referring them to a transitional care program impacts readmission rates in a primary care clinic. The PI hypothesized that identifying high-risk individuals and enrolling them in a care management program to improve their health would lessen their need for inpatient and other high-cost healthcare services.

The PICOT question for this project is as follows: In a primary care clinic, does provider (P) education on the identification and referral of eligible patients to a care management program (I) increase referrals to the program and decrease the rate of hospital readmissions (O) compared with the pre-intervention rates (C) within a 3-month period (T)? The intervention involved educating full-time primary care providers at a Southeast Texas clinic on using the Community Assessment Risk Screen to identify patients at high risk of being readmitted to the hospital. The project observed the clinic’s readmission rate and number of referrals before and after the implementation of the educational presentation. The data were audited over 3 months to determine if the intervention led to an improvement (i.e., a 5% increase in the number of referrals and a 5% decrease in readmission rates).

The findings showed a 43.48% decrease in the readmission rates after the intervention and a 200% increase in the number of patients referred to the CM program after the intervention. Reduced readmissions, improved patient outcomes, and cost savings are just a few benefits of using screening techniques to identify patients at risk for readmission. Healthcare professionals can take early action by referring patients at greater risk of hospital readmission to the care management department, where they can receive early interventions to help them avoid more serious health problems.

Changes to the current methods of healthcare delivery, such as a team-based strategy and a focus on high-risk patients, may be necessary to implement care management programs. Care management programs typically require a team-based strategy that involves several healthcare experts, such as nurses, pharmacists, and social workers. To achieve coordinated care, these experts may need to collaborate and communicate clearly. The primary care clinic needs to be ready to commit more funds to sustaining and implementing care management initiatives that lower readmission rates.

Committee Chair/Advisor

Abida Solomon

Committee Member

Jerrel Moore

Committee Member

Stacy Sam

Committee Member

Sharisse Hebert


Prairie View A&M University


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Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Date of Digitization


Contributing Institution

John B Coleman Library

City of Publication

Prairie View




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