Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2020


Doctor of Nursing Practice (DNP)

Primary Advisor

Beverly K. Lunsford, PhD, RN, FAAN; Lyn Stankiewicz Losty, PhD, MBA, RN


Background: An increasing population of older adults and their need for healthcare resources, pressures hospitals to reduce per capita expenditures and incorporate population health initiatives to reduce readmissions. Multidisciplinary teams such as care transition clinics may reduce readmissions.

Objectives: This quality improvement project was implemented to (a) develop a risk assessment for readmission, (b) identify, assess, and refer geriatric patients to a care transition clinic, and (c) evaluate hospital readmission rates to determine the effectiveness of the model.

Methodology: English-speaking participants 65 years or older, who were treated in the ED and planned for discharge were recruited in a 50-bed adult emergency department (ED) in a suburban community hospital with 75,000 patient visits per year. The Community Assessment Risk Screen (CARS) and the CTM-3® tools were used to determine patients who may benefit from a referral, which was then placed in the electronic health record to the care transition clinic for follow-up within two days. Over six months a pre-intervention group (n=52) and a post-intervention group (n=55) participated. Their charts were reviewed thirty days after their initial visit to determine if they had been readmitted to the hospital.

Results: The pre-intervention group had a 36.5% readmission rate compared to the postintervention group at 23.6%. The reduction was not statistically significant (p= .145), but CARS tool item “admission within 6 months” was significant (p= .006) and CTM-3® question “I had a good understanding of the things I was responsible for in managing my health” approached significance (p= .079).

Conclusions: The CARS tool was effective in identifying patients at risk for readmission. Implementing the CARS tool to make referrals and educating patients on managing their health may decrease readmission rates.

Open Access


Included in

Nursing Commons



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