Date of Degree
Summer 2025
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Sandra Cleveland
Second Advisor
Brandee Temmis
Third Advisor
Melanie Brewer
Abstract
Problem: Postpartum women with preexisting chronic conditions are at increased risk of hospital readmissions due to fragmented care transitions and poor follow-up adherence. At the project site, the 30-day postpartum readmission rate was 10%, exceeding the national benchmark of 7.15%. Gaps in standardized discharge planning and limited patient engagement were identified as contributing factors.
Aim of the Project: The aim of this quality improvement (QI) project was to reduce 30-day postpartum readmissions in women with chronic health conditions by implementing an evidence-based transitional care toolkit within a women’s outpatient clinic.
Review of the Evidence: Evidence supports the use of structured, evidence-based transitional care to improve maternal outcomes and reduce hospital readmissions. Literature highlights that follow-up appointment adherence and standardized discharge processes significantly enhance continuity of care. The Agency for Healthcare Research and Quality (AHRQ) transitional care toolkit, when adapted and integrated into the women’s health clinical workflows, has been shown to improve transitional care effectiveness.
Project Design: This QI project used the Institute for Healthcare Improvement model and incorporated three Plan-Do-Study-Act (PDSA) cycles to test and refine toolkit implementation. The OhioHealth Change Management Model guided stakeholder engagement, baseline and post-implementation readiness assessments, and strategic communication planning to promote long-term sustainability.
Intervention: The transitional care toolkit was adapted for postpartum use and introduced to clinical and administrative staff over a 12-week period. Components included a Pre-Intervention Assessment, a clinician checklist, a patient Appointment Aide, and structured team education. Weekly huddles and direct observation supported integration into patient encounters.
Significant Findings/Outcome: Following implementation, postpartum readmissions decreased by 2.86%, with toolkit compliance reaching 89.3% and follow-up attendance increasing to 78.6%. Staff engagement and confidence in using the toolkit improved across PDSA cycles. Barriers such as workflow inefficiencies and documentation gaps were addressed through targeted training and leadership support.
Implications for Nursing: The project demonstrates that standardized transitional care improves maternal outcomes and enhances continuity. It aligns with the IOM’s domains of effective, patient-centered, and timely care and supports the IHI Triple Aim by reducing readmissions and promoting safe care transitions in high-risk postpartum populations.
Recommended Citation
La Fleur, Cassidy, "Implementing an Evidence-Based Transitional Care Toolkit to Reduce Postpartum Readmissions in Women with Chronic Conditions" (2025). Doctor of Nursing Practice (DNP) Scholarly Project. 19.
https://fuse.franklin.edu/dnp-project/19
Rights
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