Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2024


Doctor of Nursing Practice (DNP)

Primary Advisor

Dr. Mercedes Echevarria


Background: In 2013, Medicare penalties for high hospital readmission rates spurred initiatives to reduce these figures. Despite efforts, 25% of elderly patients are readmitted within 30 days post-discharge, often due to unaddressed Social Determinants of Health (SDoH) like food, housing, and medication access.

Objectives: The project aimed to assess the effectiveness of interventions targeting SDoH for patients over 65 receiving home care services. It specifically sought to evaluate the impact of these interventions on 30-day readmission rates, focusing on addressing food, housing, and medication insecurities.

Methods: This project evaluated interventions targeting SDoH in-home care among patients over 65 to reduce 30-day readmission rates. Utilizing evidence-based practices, the project involved SDoH screening within 72 hours of home care initiation, skilled nursing, telephonic touchpoints ("Tuck-In Calls"), and a resource and education program for 507 Medicare-eligible patients.

Results: The project achieved full clinician training on SDOH, which, along with the other interventions, significantly reduced hospital readmissions. A paired sample t-test showed a decrease in readmission rates (t (3) = 14.27, p< 0.001) and improved patient outcomes (t (3) = - 18.39, p< 0.001). Screening of 507 patients identified 25.89% with SDOH issues, which were subsequently addressed. A chi-square test confirmed Tuck-in calls significantly impacted readmissions (X2 (1, N=507) = 19.02, p< 0.001), and a chi-square test confirmed the effectiveness of provided resources in reducing readmissions (X2 (1, N = 507) = 4.32, p < 0.05).

Conclusion: The project effectively reduced hospital readmissions among elderly patients by addressing Social Determinants of Health (SDoH) through clinician training, targeted screenings, and personalized interventions, including tuck-in calls and resource allocation. This comprehensive approach improved patient outcomes and demonstrated the value of integrating SDoH considerations into post-discharge care.

Open Access


Available for download on Saturday, October 04, 2025