DNP Scholarly Projects


Background: More than 25 million people are readmitted to the hospital within 30 days of nursing home admission. With most nursing home patients receiving Medicare, Medicaid, or other publicly funded services, readmissions significantly burden the healthcare system. Poor communication within nursing homes may contribute to poor health outcomes and unplanned hospital readmissions. Purpose: To reduce readmission rates at two skilled nursing facilities by improving staff communication through consistent use of the INTERACT STOP AND WATCH (SW) tool. Design: The quality improvement project reviewed all admissions, transfers, and readmissions occurring before and during the project to determine the impact of the SW tool use on readmission rates. The project utilized the Focus Analyze Develop Execute (FADE) Model. Results: A total of 7,132 SW tools were completed for skilled patients. The 30-day readmission rates at NHC Sparta decreased from 9.96% 3 months before the project to 6.47% during the project. The 30-day readmission rates at NHC McMinnville likewise noted a reduction in readmissions — 39.37% to 28.18%. Some evidence of inverse correlations exist between use of the SW tool and 30-day skilled patient readmission rates (r (4) = -.660, p = .154), as well as, a between all 30-day project readmissions and all of the completed SW tools (r (4) = -.758, p = .081). Recommendations: Future consideration for naming an INTERACT Champion, implementing the SW tool electronically, and implementing more INTERACT tools.



First Advisor

Linda Wofford

Second Advisor

David Phillippi

Scholarly Project Team Member

Vicki Dodson

Scholarly Project Team Member

Linda Hunter

Scholarly Project Team Member

Cindy Tilton


Nursing, School of


Health Sciences & Nursing, Gordon E. Inman College of

Document Type

Scholarly Project


Doctorate of Nursing Practice (DNP)

Degree Level


Degree Grantor

Belmont University


readmissions, STOP and WATCH, INTERACT, communication, skilled nursing