Improving Care Coordination to Reduce Emergency Room Visits Among High-Risk Patients Through a Nurse-Led Transitional Care Program at Sage Health Over a 6-Week Period

Improving Care Coordination to Reduce Emergency Room Visits Among High-Risk Patients Through a Nurse-Led Transitional Care Program at Sage Health Over a 6-Week Period

Improving Care Coordination to Reduce Emergency Room Visits Among High-Risk Patients Through a Nurse-Led Transitional Care Program at Sage Health Over a 6-Week Period

I. Project Overview

This six-week capstone project aims to implement and evaluate a nurse-led transitional care program at Sage Health Clinic , a primary care facility serving an underserved urban population. The intervention will focus on improving post-discharge follow-up, medication reconciliation, chronic disease education, and telehealth support for high-risk patients with conditions such as hypertension, diabetes, COPD, and heart failure. The goal is to reduce preventable emergency room (ER) visits and enhance patient engagement in self-care.

II. Background and Significance

Problem Statement

Frequent ER visits among high-risk patients often result from poor care coordination, lack of timely follow-up, and inadequate chronic disease management. At Sage Health Clinic, data show that approximately 30% of adult patients have visited the ER twice or more in the past three months, many for avoidable complications related to uncontrolled chronic illnesses.

Relevance to Advanced Nursing Practice

Advanced practice nurses (APNs) are well-positioned to lead transitional care interventions due to their expertise in health coaching, patient education, and systems-based quality improvement. This project aligns with national efforts to shift toward value-based care and demonstrates the critical role of APNs in reducing healthcare utilization through proactive, patient-centered care models.

Organizational Alignment

The proposed project supports Sage Health’s mission to improve community health outcomes by addressing barriers to continuity of care. It also aligns with broader healthcare trends emphasizing preventive care, population health management, and integration of technology into clinical workflows.

III. Literature Review Summary

Research shows that transitional care programs led by nurses can significantly reduce hospital readmissions and ER visits:

• A systematic review found that nurse-led transitional care reduced hospital readmissions by up to 30% within 30 days post-discharge (Naylor et al., 2011).
• Coleman’s Transition Intervention Model emphasizes the importance of structured discharge planning and early follow-up to ensure care continuity.
• Telehealth has been shown to improve access to care for patients facing transportation or mobility challenges (Bashshur et al., 2016).

Key principles guiding this project include:

• Timely post-discharge follow-up
• Medication safety and adherence
• Patient empowerment through self-management education
• Use of technology to bridge gaps in care

IV. Project Objectives and Timeline

Phase 1: Baseline Assessment (Week 1)

Objective:

Identify high-risk patients, understand reasons for frequent ER use, and assess current transitional care processes.

Activities:

• Retrospective chart review of patients with ≥2 ER visits in the last 3 months.
• Identify common diagnoses and triggers leading to ER visits (e.g., uncontrolled blood pressure, hypoglycemia, exacerbations of COPD).
• Survey clinic staff and providers to assess current post-discharge practices and identify gaps.
• Develop a patient recruitment list in collaboration with case managers and social workers.

Phase 2: Intervention Implementation (Weeks 2–5)

Objective:

Deliver a structured, nurse-led transitional care program to improve post-discharge outcomes and reduce ER visits.

Interventions:

1. Post-Discharge Follow-Up Protocol

   • 48-hour phone call : Conducted by the DNP student or assigned nurse to assess symptoms, medication adherence, and clarify discharge instructions.
   • 7-day in-person visit : Scheduled at Sage Health to reassess condition, perform vital signs check, and adjust treatment plans if needed.

2. Medication Reconciliation & Adherence Support

   • Review medications during initial follow-up and reconcile with discharge prescriptions.
   • Provide visual aids and written summaries of medication regimens.
   • Address cost barriers by connecting patients with pharmacy assistance programs.

3. Chronic Disease Self-Management Education

   • Weekly group sessions covering:
     • Hypertension: diet, salt intake, home BP monitoring