Date of Award

5-2026

Document Type

Project

Degree Name

Master of Science in Health Services Administration

Department

Health Science and Human Ecology

First Reader/Committee Chair

Paulchris Okpala

Abstract

Within 30 days of the discharge, hospital readmissions continue to be one of the significant problems in healthcare organizations and are commonly seen as the measure of care quality, coordination, and efficiency. The high readmission rates indicate the disconnect between inpatient and outpatient settings, patient education, medication reconciliation, and discharge planning. They also have high financial implications in value-based reimbursement settings. The proposed project will be a descriptive and analytical literature review studying the effects of structured post discharge follow up interventions such as scheduled telephone calls, telehealth visits, and home based outreach on preventing unnecessary hospital readmission and enhancing patient engagement.

Systematic reviews of peer-reviewed studies, reports on healthcare quality in the country, and community health evaluation in the region were carried out to determine evidence-based practices that relate to positive transitional care outcomes. The results were structured by the Donabedian Structure-Process-Outcome model and the Triple Aim framework of the Institute of Healthcare Improvement to determine the relationship between the organizational structures and care processes and the outcomes of patients, population health, and healthcare expenses. Quantitative outcomes mentioned in this project are synthesized ranges and effect sizes which were found in the literature and which are not primary data collection and local intervention outcomes.

The data always shows that structured follow-up interventions are related to reduced 30-day readmissions, better medication compliance, increased patient satisfaction, and earlier detection of post-discharge complications. The following are some of the characteristics of effective programs: contact with the patient within the first week of discharge, interdisciplinary cooperation of nurses, pharmacists, case managers, and social workers, a standard of discharge education based on principles of health literacy, and the inclusion of the telehealth and telemonitoring tool. Administrative accountability and leadership participation were named as the key factors that determined sustainability and success of the programs. Companies that incorporate follow-up measures on the performance dashboards, and align transitional care initiatives with quality enhancement initiatives show more significant consistency in results.

The project specifically focuses on the healthcare setting of San Bernardino County, where chronic disease rates are high, there are socioeconomic barriers, and transportation restrictions, and digital access is also unreliable, which makes care transitions difficult. Although the structured follow-up has been found to be an effective strategy in the national evidence, it must be implemented within the resource-constraining context with the use of standardized workflows, culturally competent communication strategies, and community-based partnerships to implement any social determinants of health.

This project transforms clinical evidence into organizational recommendations by synthesizing existing literature on the topic using an administrative and systems-level lens. It also offers healthcare leaders an organized platform on how to design sustainable post-discharge follow-up programs that are also in line with value-based care priorities. Finally, empowering continuity of care following discharge with leadership-enhanced, technology-empowered, and interdisciplinary models is a strategic direction of minimizing preventable readmissions, enhancing patient experience, and elevating population health outcomes.

Download

  Contact Author

Share

COinS