Reducing 30-Day Readmissions Through Nursing Science: An Application of Transitions Theory With Best Practice Guidelines.

The Transition Management Model was developed by and for nurse care coordinators at an Independent Health Network to reduce Medicare and Medicaid 30-day readmission rates. Preimplementation assessment revealed the need for a nursing science framework to effectively reduce 30-day readmissions. The model was developed through thoughtful integration of transitions theory with best practice guidelines set forth by Project BOOST. Initial results of the Transition Management Model produced a decline in readmission rates by 11%. The Transition Management Model initiative can serve as an exemplar for the integration of transitions theory to best practice guidelines to effectively reduce 30-day readmissions.