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Evaluation of a Hospital

Community Partnership to Reduce 30-Day Readmissions

Wilcox, Diahann, DNP, APRN, ACNP-BC; McCauley, Paula S., DNP, APRN, ACNP-BC, CNE; Delaney, Colleen, PhD, RN, AHN-BC; Molony, Sheila L., PhD, APRN, GNP-BC

doi: 10.1097/NCM.0000000000000311

Purpose: To evaluate the ComPass2c program by (1) effectiveness in reducing 30-day hospital readmissions, (2) reach of program into target population, and (3) implementation of key program elements.

Primary Practice Setting: An academic hospital in New England (John Dempsey Hospital).

Methodology and Sample: Retrospective analysis of Medicare fee-for-service (FFS) beneficiaries hospitalized at John Dempsey Hospital between May 1, 2012, and November 30, 2014.

Results: The program reached 34% of eligible Medicare FFS beneficiaries (n = 832; 61% female, mean age = 79 years). The unadjusted 30-day all-cause readmission rate decreased from 21% to 16.2% (p = .03). Implementation was high for postdischarge phone calls (89%) but low for home visits (34%). The mean change in patient activation scores following completion of the program was 0.15 (SD = 4.79), with no change in patient activation level, χ2 (6) = 3.82, p = .70.

Implications for Case Management Practice: The ComPass2c program was consistent with the philosophy and standards of case management practice. Case managers will want to utilize an evidence-based instrument with real-time information to identify patients at risk for 30-day readmission. A physical presence of ComPass2c coaches within the hospital enabled a strong hospital–community-based organization (CBO) partnership, facilitating the coordination, communication, and collaboration. Case managers will want to advocate for policy incentivizing hospital–CBO partnerships. Patient activation is essential; case managers may benefit from training in motivational interviewing to improve patient activation and outcomes. Additional research is needed to further elucidate and mitigate barriers to posttransition home visits and patient activation.

Diahann Wilcox, DNP, APRN, ACNP-BC, is currently a Nurse Practitioner at the University of Connecticut Health Center in pulmonary medicine. Her work focuses on ensuring safe and quality care for individuals with chronic conditions.

Paula S. McCauley, DNP, APRN, ACNP-BC, CNE, is Associate Clinical Professor and Coordinator of the Adult Gerontology Acute Care Nurse Practitioner Track at the University of Connecticut School of Nursing, Storrs, CT. She has more than 35 years in critical care and served as a director of the American Association of Critical-Care Nurses.

Colleen Delaney, PhD, RN, AHN-BC, is Associate Professor at the University of Connecticut School of Nursing, Storrs, CT. Dr. Delaney is the Coordinator of the RN-MS and Graduate Certificate in Holistic Nursing programs at the University of Connecticut.

Sheila L. Molony, PhD, APRN, GNP-BC, is Associate Professor at Quinnipiac University School of Nursing, Hamden, CT. She has more than 30 years of nursing experience in community, nursing home, and hospital settings. Dr. Molony conducts research on the meaning of “home” to older adults.

Address correspondence to Diahann Wilcox, DNP, APRN, ACNP-BC, Pulmonary & Sleep Disorders Center, 263 Farmington Ave, Farmington, CT 06030 (

The authors report no conflicts of interest.

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