Person-Centered Care Discharge Planning to Reduce Readmissions in Older Adult Populations

Background: Hospital readmissions are costly and disproportionally affect older adult populations. To reduce readmissions, hospital leaders have instituted many interventions. This project aims to evaluate the impact of implementing a person-centered discharge plan to reduce readmissions in older adult patients. Methods: The organization’s IMPROVE framework was used to implement a person-centered discharge protocol for older adult patients discharged to home with the purpose of reducing unplanned readmissions. Chart reviews were completed to gather 30-day readmission rates in this patient population prior to the implementation and during the project period. Intervention: Using a checklist that was based on the Agency for Health Research and Quality (AHRQ) IDEAL discharge, staff assessed patients’, families’, and caregivers’ preferences, biases, and values in patients who met the inclusion criteria. This was then communicated to the interdisciplinary care team and incorporated into the discharge care plan. Staff were educated on the intervention prior to the implementation of the project. Evaluation methods included pre and post-testing of staff training. Inferential and descriptive statistics compared readmission rates in the pre-and-post project implementation groups.
Results: Results did not demonstrate that implementing a person-centered care protocol reduces readmissions. Forty-nine older adult patients were included in the project and five had unplanned 30-day readmissions. However, the staff education sessions showed an increase in staff knowledge with the mean test score increasing from 8.296 to 9.515, P < .05. Conclusion: While this quality improvement project did not show a reduction in unplanned readmissions with a person-centered care discharge protocol in older adults, it did reveal the need for further studies at a time when there is not a global pandemic. The project site should continue to work to improve person-centered care to improve the care for patients.



Work Title Person-Centered Care Discharge Planning to Reduce Readmissions in Older Adult Populations
Penn State
  1. Kathleen McCrea
  2. Michael Evans, Ph.D, M.S.ED, RN, ACNS, CMSRN, CNE
  3. Madeline Mattern, D.N.P., FNP-C, CNE
  4. Oluwamuyiwa Winifred Adebayo, Ph.D, RN
  1. DNPProject, person-centered care, older adults, readmissions, IDEAL discharge
License Public Domain Mark 1.0
Work Type Project
Publication Date April 30, 2021
Deposited April 30, 2021




This resource is currently not in any collection.

Work History

Version 1

  • Created
  • Added Creator Kathleen McCrea
  • Updated Publication Date Show Changes
    Publication Date
    • 2021-04-30
  • Added Creator Michael Evans, Ph.D, M.S.ED, RN, ACNS, CMSRN, CNE
  • Added Creator Madeline Mattern, D.N.P., FNP-C, CNE
  • Added Creator Oluwamuyiwa Winifred Adebayo, Ph.D, RN
  • Added McCrea_K_Person-Centered Care Discharge Planning to Reduce Readmisions in Older Adult Populations.docx
  • Updated License Show Changes
  • Published
  • Updated