Improving Care for Patients Transitioning from Hospital Acute Care to Home

Rosha L. Hamilton, DNP, MSW, BSN; Judith A. Walloch, EdD, RN; Karen Lauer, BSN, RN, MSOLQ; Thomas W. Zoch, MD, FACEP, FACP, CPE


Nurs Econ. 2021;39(2):59-66. 

In This Article

Purpose and Objectives

The senior leaders of the system implemented this project as a pilot program with the ability to scale up. The 3-month pilot program aimed to increase TCM for patients transitioning from an inpatient hospital stay to home for self-care. The change should allow for increased TCM billing and reimbursement from 13% to 50%. This TCM pilot program's long-term goal was to reduce annual readmissions from the current rate of 15.5%. Healthcare reimbursement is decreasing, so it is imperative to utilize all revenue-generating opportunities that exist.

This quality improvement (QI) project reviewed established patient records using de-identified personal information as an aggregate of results. The pilot program was determined by the Redcap system to constitute QI and did not fit the federal definition of research. A waiver of informed consent and documentation of informed consent was approved the Bradley University Committee on the Use of Human Subjects in Research.