Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2022


Doctor of Nursing Practice (DNP)

Primary Advisor

Mary Jean Schumann, DNP, MBA, RN, CPNP-PC, FAAN; Laura Hendricks-Jackson, DNP, NEA-BC, RN-BC


Re-Engineered Discharge (RED); Skilled Nursing Facility (SNF)


Background: The growing population of people over the age of 65 years with surmounting medical complexities resulting in hospital re-admissions poses significant challenges for the healthcare system. Re-Engineered Discharge (RED) has demonstrated interventions inclusive of nursing driven discharge planning to successfully decrease hospital readmissions in Skilled Nursing Facilities (SNF).

Purpose: This aim of this quality improvement initiative was to improve discharge efficiency by implementing a modified version of RED to evaluate the effect of centralizing nursing in education and discharge processes and influence on all-cause 30-day readmission rates.

Methods: A pre and post intervention design was utilized for patient chart review (N=93, pre n=47, post n=46) and nursing surveys. The Self-Directed Learning Readiness Scale-Adult Learning Preference Assessment (SDLRS-A) and discharge surveys evaluated nurses’ (N=30) attitudes, beliefs of learning, and the discharge processes. RED education sessions were designed to improve clinical care, nursing documentation, and patient education.

Results: SDLRS-A scores indicated 87.3% nurses had high level of readiness to learn (n=24, M=235.17, SD=25.38). Mann-Whitney test showed statistical significance pre/post nurses survey median scores. All-cause 30-day readmissions were insignificant (p = .098). Chi square was significant (p = < .001) for follow-up appointments, post discharge calls, and nursing presence at multidisciplinary meetings. HCAPHS scores indicated substantial increase in nursing scores.

Conclusion: RED demonstrated centralizing nursing in patient education and discharge processes had a substantial impact on SNF patient outcomes and increased HCAPHS scores.

Recommendation: SNFs can utilize nurses to implement and sustain RED to influence readmissions and improve populations’ health outcomes for people over the age of 65 years.

Open Access




To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.