Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2022


Doctor of Nursing Practice (DNP)

Primary Advisor

Cara Padovano, DNP, APRN; Michael McMahon, MD; Colleen Bell, RN, BSN, CCRN, SCRN


Transitional Care Model; Ischemic Stroke; TIA Patients


Background: Poor continuity of care after hospitalization can increase the risk of adverse health outcomes such as unplanned readmissions for stroke and transient ischemic attack (TIA) patients. Transitional care models (TCMs) can be used to improve the coordination of care post-discharge.

Objectives: The purpose of this doctoral Quality Improvement (QI) project was to develop, implement, and evaluate a TCM for ischemic stroke/TIA patients over a 3-month period. This project had four aims: 1) to decrease the unplanned 30-day readmission rate, 2) for all eligible patients to be enrolled after discharge, 3) to have all enrolled participants receive all components, and 4) for all participants to express satisfaction with the TCM.

Methods: A TCM was designed and piloted for adult patients discharged home from the project site hospital with a diagnosis of ischemic stroke or TIA. The TCM consisted of patient education materials, scheduling of a primary care provider appointment, and two phone surveys at 7-days and 30-days post-discharge. Unplanned 30-day readmission rates were compared before and after project implementation.

Results:Nine participants were enrolled. Five of these participants (55.6%) completed both the 7-day and 30-day surveys and comprised the intervention group. 100% of all eligible patients were contacted for enrollment. The post-intervention mean 30-day readmission rate of 3.7% (SD = 2.97) was significantly lower (p

Conclusions: While this was a small pilot project, results demonstrated that the TCM may have had a positive impact on readmission rates. It was also well-received by participants and provided useful feedback on the hospital’s stroke program. Long-term implementation of a TCM may be of benefit in this patient population to improve health outcomes.

Open Access




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