Graduation Semester and Year
Spring 2026
Document Type
DNP Project
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Thomas Dombrowsky, PhD, RN
Abstract
Background: Hospital readmissions among Medicare beneficiaries remain a major quality concern and are often associated with social determinants of health (SDOH) and care transition gaps. Targeted discharge interventions that address self‑management needs and follow‑up barriers may reduce avoidable readmissions. Objective: To reduce readmissions by implementing a bundled intervention addressing social determinants of health (SDOH), care‑transition gaps, and inadequate post‑discharge primary care follow‑up. Methods: Medicare Advantage (MA) members aged ≥45 were included. A total of 249 members accounted for 275 overall admissions during the project period; 191 admissions (69.5%) received at least one intervention component (informational discharge packet, face‑to‑face encounter, and/or multidisciplinary follow‑up support) regardless of the prior admission status. Readmission outcomes and SDOH correlations were assessed, including a subgroup analysis for one delegated health plan (DHP). Results: During the eight-week project period, 269 admissions were recorded after excluding six patients who expired or were discharged to hospice. Twenty-six readmissions occurred, resulting in an overall 30-day readmission rate of 9.7% (n = 269). Of the 269 admissions, 68 were attributed to DHP members, with 7 readmissions (n=68; 10.3%), compared with 19 readmissions among 201 (9.5%) admissions across other plans. Overall readmission rates decreased from 12% in 2024 to 9.7% during the 2025 project period, while DHP readmission rates decreased from 24% to 10.3% over the same timeframe. After all exclusions were applied, 101 unique patients were analyzed to examine the association between intervention status and hospital readmissions. Conclusion: Although statistical significance was not achieved, readmission rates declined, suggesting the bundled intervention may be beneficial. Additional data and further analysis are needed. Keywords: readmissions, patient engagement, social determinants of health, care transitions, interventions
Keywords
Readmissions, Patient engagement, Social determinants of health, Care transitions, interventions
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Hugaboon, MSN, RN, Derinda, "Empowering Patient Engagement in Effort to Reduce Readmissions" (2026). Doctor of Nursing Practice (DNP) Scholarly Projects-Archive. 138.
https://mavmatrix.uta.edu/nursing_dnpprojects/138