Date Available


Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Karen Stefaniak

Clinical Mentor

Dr. Melissa Czarapata

Committee Member

Dr. Karen Butler


Preventable readmissions are a significant cost burden to hospitals and healthcare systems and are associated with overutilization of healthcare services, suboptimal health outcomes, and reduced quality-adjusted life years (QALYs) for patients. Low health literacy is an independent patient risk factor for preventable readmissions following hospital discharge. Improving transitional care practices through targeted and timely communication with community-based healthcare providers, within the framework of Naylor’s Transitional Care Model, may reduce readmission rates for patients with low health literacy. An experimental pilot study was conducted on a standard medical-surgical unit to assess local levels of low health literacy among sepsis patients utilizing the Basic Health Literacy Screen assessment tool. Patients meeting criteria for low health literacy were randomly assigned to a control group or treatment group, with the treatment group receiving a warm handoff intervention from the discharging hospitalist provider to the patient’s PCP. The impact on 30-day readmission rates between the two groups was evaluated. Data obtained did not show an association between warm handoffs and readmission rates. Study participants may represent a unique population as all resided in rural counties and BHLS scores revealed twice the expected rates of low health literacy. Hospitalist providers were willing to provide warm handoffs, but real-time interactions were limited and no provider documented the warm handoff attempt in the medical record or with nonbillable codes. Using Naylor’s Transitional Care Model as a guide, warm handoffs remain an integral part of high-quality transitional care and more research is needed to determine their effectiveness on readmission rates for sepsis patients.

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