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Document Type

DNP - University Access Only

Award Date


Degree Name

Doctor of Nursing Practice (DNP)


Graduate Nursing

First Advisor

Kay Foland


elderly, transition of care, acute care hospital, skilled nursing facilities, handoff, bidirectional communication, protocol, standardization, readmissions


Problem: The elderly are a vulnerable population, particularly during transitions of care. The elderly may be hospitalized in an acute care hospital and subsequently transferred to a skilled nursing facility (SNF). A high percentage of elderly patients transferred from acute care hospitals to SNFs are readmitted within 30 days. Failures in communication during a handoff between sender and receiver during this transition of care may lead to poor outcomes and avoidable readmissions. Purpose: The purpose of the DNP practice innovation project was to pilot a standardized bidirectional transition of care handoff protocol between sending and receiving nurses utilizing the best available evidence. Methods: The practice innovation project utilized a descriptive pilot of change utilizing The Iowa Model of Evidence-Based Practice to Promote Quality Care. Sample: 42 Medicare beneficiary nursing home patients transferred from an acute care hospital to a SNF and the receiving nurses in the SNF setting. Additional study included a survey of the perceptions of the handoff between sending and receiving SNF nurses utilizing a pre-survey and post-survey. Setting: A 500 bed hospital in the Upper Midwest and six local nursing homes. Results: The Transition of Care Handoff Protocol did not produce any measurable decrease in 30 day SNF readmissions within the sample. There was a statistically significant improvement in nursing home nurses’ perception with the handoff process among handoff interactions as measured by pre- and post-survey comparisons. Conclusion: A standardized transition of care handoff protocol demonstrated a statistically significant improvement in nursing home receiving nurses of bidirectional communication and did not reduce Medicare beneficiaries’ hospital to skilled nursing home readmissions.

Library of Congress Subject Headings

Continuum of care -- Quality control
Older people -- Care


Includes bibliographical references (pages 75-81)



Number of Pages



South Dakota State University


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