CDM2 Task 1: Transitions of Care and Readmission Prevention Plan

Western Governors University D028 Advanced Health Assessment for Patients and Populations requires students to complete the CDM2 performance assessment by developing a transitions of care plan for a selected patient scenario drawn from the CMS Hospital Readmission Reduction Program conditions, incorporating social determinants of health and evidence-based interventions.

In this performance assessment for Western Governors University course D028 Advanced Health Assessment for Patients and Populations, students apply advanced assessment skills and population health principles to reduce preventable hospital readmissions. The task centers on a patient case from the CMS Hospital Readmission Reduction Program, identification of one social determinant of health, selection of evidence-based practices, and construction of a communication and follow-up plan aligned with established transitions of care standards.

Competencies

• The graduate performs advanced health assessment of patients and populations.
• The graduate analyzes social determinants of health that influence readmission risk.
• The graduate designs evidence-based interventions and transitions of care plans that improve outcomes for patients covered under the CMS Hospital Readmission Reduction Program.
• The graduate applies public health intervention levels and standards of transitions of care to clinical practice.

Introduction

Students select one patient scenario from the Supporting Documents that corresponds to a CMS Hospital Readmission Reduction Program condition or procedure. The completed plan must address the selected patient’s readmission risk, one social determinant of health, evidence-based practices that reduce readmission, public health interventions at multiple levels, and a detailed communication plan that meets transitions of care standards.

Requirements

The submission must be original work. No more than a combined total of 30 percent of the submission and no more than a 10 percent match to any one individual source may be directly quoted or closely paraphrased from sources, even if cited correctly. Use the originality report provided upon submission as a guide.

Submit a written plan of suggested length 4–6 pages in APA format that includes the following elements:

1. Brief discussion of the purpose of the CMS Hospital Readmission Reduction Program, the conditions and procedures included, and how the advanced professional nurse uses the Hospital-Specific Report to promote outcomes.
2. Identification of the selected patient scenario and one social determinant of health that increases the patient’s readmission risk. Propose one concrete intervention that addresses that social determinant.
3. Identification of one evidence-based practice that reduces hospital readmission for the selected patient’s condition. Support the practice with current scholarly evidence.
4. Discussion of one public health intervention for the selected patient at each of the following levels: individual, community, and systems.
5. Application of five standards of transitions of care. Develop a detailed communication plan that operationalizes Standard 5 for the selected patient.

Rubric Criteria (Competent Performance)

• CMS HRRP discussion is accurate, concise, and correctly links the Hospital-Specific Report to nursing practice.
• Selected patient and social determinant of health are clearly identified; the proposed intervention is specific and feasible.
• Evidence-based practice is relevant to the patient’s condition and supported by current scholarly sources.
• Public health interventions at individual, community, and systems levels are distinct and appropriate.
• Five transitions of care standards are addressed; the communication plan for Standard 5 is detailed, patient-centered, and actionable.
• APA formatting, scholarly support, and originality thresholds are met.

Why This Matters in Practice

Preventable readmissions remain a major driver of cost and patient harm. Advanced practice nurses who systematically address social determinants and execute structured transitions of care plans reduce 30-day readmission rates for high-risk conditions and improve continuity across care settings.

FAQ

Which patient scenarios may I choose for the D028 CDM2 task?
Select one patient case from the Supporting Documents that corresponds to a condition or procedure included in the CMS Hospital Readmission Reduction Program.

How many social determinants of health must I address?
Identify and intervene on one social determinant of health that directly elevates the selected patient’s readmission risk.

What length is expected for the written plan?
The suggested length is 4–6 pages excluding title and reference pages. Complete coverage of every required element is the primary evaluation criterion.

Must the evidence-based practice come from a systematic review?
Higher-level evidence is preferred, yet any current peer-reviewed source that supports the practice for the selected condition is acceptable when properly cited.

What file formats are accepted?
PDF, DOC, or DOCX only. Live links are not accepted.

Sample Writing Help

Patients discharged after heart failure exacerbation face elevated 30-day readmission risk when transportation barriers and limited health literacy remain unaddressed. Advanced professional nurses reduce that risk by first confirming the patient’s status under the CMS Hospital Readmission Reduction Program and then targeting one modifiable social determinant. Providing a scheduled ride-share voucher for the first post-discharge cardiology visit combined with teach-back education on daily weight monitoring constitutes a feasible individual-level intervention. Community-level support may include referral to a local heart-failure education class, while systems-level change involves updating the electronic discharge checklist to flag transportation needs automatically. These layered actions align with current transitions of care standards and demonstrably lower readmission rates when implemented consistently, as shown in analyses of structured post-discharge support programs.

Layered Intervention Design

Effective plans move beyond single interventions. Pairing an individual teach-back session with a community-based peer support group and a systems-level automatic referral order creates redundancy that protects against single-point failure. Recent quality-improvement reports indicate that multi-level bundles produce larger absolute reductions in readmission than isolated patient education alone. Nurses who document each level explicitly also generate clearer data for subsequent Hospital-Specific Report review and organizational improvement cycles.

Communication Plan Pitfalls

Many submissions describe general follow-up calls yet omit the specific content, timing, and responsible party required by Standard 5. A complete communication plan names the clinician who will call within 48 hours, lists the exact questions that assess weight gain, medication adherence, and symptom progression, and states the escalation pathway if red-flag symptoms appear. Including the patient’s preferred contact method and a backup contact further strengthens continuity and satisfies evaluator expectations for patient-centered detail.

References

Centers for Medicare & Medicaid Services. (2024). Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp

Coleman, E. A., et al. (2021). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine. https://doi.org/10.1001/archinternmed.2006.18

Naylor, M. D., et al. (2018). The care span: The importance of transitional care in achieving health reform. Health Affairs. https://doi.org/10.1377/hlthaff.2011.0041

Agency for Healthcare Research and Quality. (2023). Transitions of care. https://www.ahrq.gov/patient-safety/settings/hospital/resource/transition.html

Submit the D028 Task 1 written plan of 4–6 pages that reduces preventable readmissions for a CMS HRRP patient through targeted social determinant intervention and structured transitions of care.

Assessment: Clinical Practice Experience (CPE) Phase 2 and Phase 3 Completion.

Students finalize the remaining CPE deliverables that include evidence-based practices to reduce readmission, public health interventions at three levels, discussion of the five transitions of care standards, and the detailed communication plan. The completed CPE Record is signed and uploaded separately while the OneNote e-portfolio link is submitted to document all required indirect clinical hours for D028.