Date Available


Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Melanie Hardin-Pierce

Clinical Mentor

Dr. Margie Summers

Committee Member

Dr. Martha Biddle



Objective: The purpose of the project is to develop a specialized and evidenced-based transitional care program including post-discharge phone calls for the older adult population within the University of Kentucky Good Samaritan Hospital system.

Background: Problems in the post-discharge period such as failure to communicate/understand discharge instructions appropriately and lack of timely follow-up appointment with primary care physician lead to increased readmission rates. Utilizing post-discharge phone calls will facilitate prompt communication with the patient after discharge ensuring full understanding of the plan of care.

Aim: Assess the readmission rates of those who received post-discharge phone calls compared to those who did not receive a phone call, assess the sociodemographic variables and co-morbidity index within the population, evaluate the process of post-discharge phone calls in regards to the ability to reach patients within a two-day post-discharge time frame and the amount of time needed for each phone call, and categorize most frequent patient concerns addressed during phone calls in order to improve the discharge process

Design: This was randomized controlled trial in which 30 patients will be randomly assigned into a group that receives a post-discharge phone call (n=15) and a group that does not receive a phone call (n=15).

Methods: This project was a pilot study in which the primary investigator will be devoted to the discharge process and provide follow-up phone calls using a preapproved script within forty-eight hours after discharge.

Results: There were 19 males and 11 females with an average age of 71.1 years old. The most common education level among the groups was high school graduate, encompassing 36.6% for males and 13.3% females. The Fisher exact test statistic was 0.4828, which is not statistically significant at p

Conclusions: In 2015, the 7th Floor of Good Samaritan piloted a program enhancement project titled BOOST. BOOST, Better Outcomes by Optimizing Safe Transitions, is a program with a set of tools designed to improve care transitions from the hospital to home. Adding post-discharge phone calls to this tool kit will be a valuable tool to reduce 30-day readmissions in the older adult population.