Date of Award

Fall 12-22-2015

Degree Type

Final Project

Degree Name

DNP Doctor of Nursing Practice




Maryanne Barra-Schneider, DNP

Committee Member

Mary Ellen Roberts, DNP

Committee Member

Lucy Ankrah


Purpose:Transitional care is time-limited, with the goal of ensuring safety and health continuity for at-risk patients with chronic obstructive pulmonary disease (COPD) as they move from one setting to the next. An acute care episode of COPD ranges from relatively healthy adults to adults with multiple chronic conditions or those in the end-of-life phase. The primary quality concern of an urgent need to improve health care is in response to the gaps of sufficient experience to manage patients with COPD, leading to hospital readmissions. Implementation of standards of care for the improvement of health-related quality of life (HRQL) of COPD patients is intended to reduce the rate of adverse events and hospital readmissions. Method: The project was implemented in collaboration with the transitional health care team at a local medical hospital. For the challenge of high levels of readmissions, coaching models for patient advocacy required continued tracking to decrease readmissions within 30 days to avoid penalties. The goal was to reduce the all-cause readmission rate by 20%. A detailed plan of action customized for the purpose of designing strategic interventions addressed health care reform. Practical education aimed at staff, patients, and family members are the standard for the delivery of health care for patients with COPD. Decision supports for a change of behavior and adaptations had a significant role in client care. Case managers, nurse practitioners, physicians, nurses, pharmacists, and dieticians formulated solutions in patient safety during the acute phase. As a result, cost-effective care reduced medical costs, decreased recurrent hospital stays, and improved patient satisfaction. Findings: Cultures, socioeconomics, and gender had an effect on the transitional approach. Coach status had positive effects on the population’s shared decision-making requirements. Religion and health disparities considered, patients had universal needs across the REDUCING RECURRENT COPD ADMISSIONS 8 population. The biggest impact made was with pharmacy involvement and elderly polypharmacy involving potential adverse drug events. The pharmacist counseled patients on medication with accuracy. Case studies and preliminary results identified gaps. Results identified multiple errors per patient. Intervention scores had a greater improvement over a nine month period. Conclusions: Citizen ties to a community-based organization (CBO) are critical for the improvement of the quality of life in low-income areas. Services and resources with strategies expand the legitimacy of low-income communities with a devoted effort for goal accomplishment (Walker & McCarthy, 2010). Implementing cost containment and competitive strategies for an alternate health care delivery system generates savings and improves the management of chronic disease. Determining costs associated with exacerbations of COPD and an acute exacerbation of chronic bronchitis (AECB) is specific to controlling costs derived from treatment failure and hospitalization. The leading preventable risk factor associated with chronic lung disease for further study is smoking. Determining the underlying addiction and further education may also be an area for further research to consider. Treatment failure causes further medical visits, emergency room visits, and potentially extended hospital stays (Miravitlles et al., 2002). Access to clinical excellence for the successful transition from the hospital, across settings, prevented readmissions. The impact of reducing recurrent admissions for patients discharged with chronic obstructive pulmonary disease improved patient care outcomes.