Transition of Care from Hospital to Home: Faith Community Nurses Fill the Gap: A Program Evaluation
Loading...
Date
2018-05
Authors
Journal Title
Journal ISSN
Volume Title
Publisher
The Ohio State University
Abstract
High risk patients over the age of sixty-five (65) demonstrate a 34 % readmission rate to the hospital within 30 days of discharge. Transition of Care Models have shown to reduce the hospital readmission rate by up to 67% by offering coordination and continuity of care. The purpose of the Doctor of Nursing Practice evidence-based project was to evaluate a Congregational Transitional of Care (CTOC) program designed to accommodate the faith community following a hospitalization to reduce inpatient readmission. The CTOC program uses a volunteer faith based registered nurse (VFB-RN) in the congregation to make contract with a parishioner following hospital discharge to determine if follow-up appoints have been completed and if other commonly experienced concerns such as perceptions of spiritual, emotional and physical health, medication management were addressed. The VFB-RN also asks if the patient experienced a rehospitalization. Data on the number of people who participated in the CTOC were calculated. The 30-day readmission rate was calculated and compared to the baseline rate. Forty-four (44) participants entered the CTOC program between July 26, 2017 and December 31, 2017. A total of 93% (n=41) participants completed the CTOC program. Those who follow-up with a primary care provider 93% (n=41). At 30-day phone call 1 or 2.4% experienced a hospital readmission. A CTOC program using a VFN-RN can be effective in reducing 30-day readmission in the faith community.
Description
Keywords
Transitional Care, Transition of Care Model, 30-day readmission rate, Faith based nurse, Faith Community Nurse, discharge home