Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

Ron D. Yolo

Second Advisor

Joan P. Kearney


Home-bound patients aged 65 and older are at the highest risk for avoidable 30-day hospital readmission: a factor contributing to rising healthcare costs and comprising over 30% of Medicare’s spending. The Hospital Readmission Reduction Program (HRRP) deemed that one in five patients that were discharged from the hospital were readmitted within 30 days, resulting in an annual waste of $17 billion. The increase in homebound older patients, coupled with ongoing avoidable 30-day readmissions, resulting in poorer quality of life, makes this a critical issue for the U.S. healthcare system. A key gap identified in the prevalence of avoidable 30-day readmissions is a communication breakdown between medical entities. Most homebound older patients are medically complex and are unable to obtain medical care in the traditional manner. Therefore, newer care delivery models should be further refined. A well-implemented interprofessional communication protocol can improve the delivery of healthcare across the continuum. The goal of this DNP project was to develop, implement, and evaluate an evidence-based Interprofessional Communication Protocol within a Multidisciplinary Hospital at-home program (MHAHP) to reduce 30-day readmission rates in the older homebound patient population. A comparative analysis of 30-day readmission rates was conducted pre-and post-project using a one-tailed, one-sample proportion test and found that the readmission rate was 0.6% lower than the baseline rate but not statistically significant (95%CI: 0% to 34% lower. P = 0.5%. X2 = 0). Staff pre-and-post-knowledge tests was compared using a Paired T-test and found that the difference was statistically significant (t = 6.29, p < 0.001). The participants gained an average of 16 points (SD = 9.9) from pre- to post-test scores (95%CI: 10.5 to 21.6). The staff program evaluation survey of the training session was analyzed using descriptive statistics and found a median of 5 and an interquartile range of 0, the mean score was 4.79. Standard workflows that mirror the IPCP became the norm post-project implementation.


This is an Open Access Thesis.

Open Access

This Article is Open Access