WGU D028 CDM2: Transitions of Care Coordinator CPE Guide

Assignment Brief – 2026 Spring/Summer Session

Course: D028 – Advanced Health Assessment for Patients and Populations
Program: Master of Science, Nursing (MSN) – Core
Institution: Western Governors University (WGU), Leavitt School of Health
Assessment Type: Performance Assessment – Clinical Practice Experience (CPE) E-Portfolio
Task Identifier: CDM2 – Clinical Practice Experience: Transitions of Care Coordinator
Suggested Length: E-Portfolio with multiple deliverables (see task requirements below); written components total approximately 5–7 pages
Weighting: This performance assessment is a required task for course completion.
Academic Level: Graduate (MSN)
Submission Format: APA 7th Edition for written components; e-portfolio template provided
Due Date: Refer to your course of study and mentor guidance for specific term deadlines.

Competencies Measured

This assessment addresses the following WGU competencies:

• 7104.1.1: Health Assessment – The graduate conducts comprehensive health assessments across the lifespan, integrating biological, psychological, social, and environmental factors.

• 7104.1.2: Clinical Reasoning – The graduate uses clinical reasoning to interpret assessment findings and develop evidence-based plans of care for patients and populations.

• 7104.1.3: Transitions of Care – The graduate evaluates and implements strategies to support safe, effective transitions of care across the healthcare continuum.

• 7104.1.4: Evidence-Based Practice – The graduate integrates current evidence to reduce hospital readmissions and improve patient outcomes.

• 7104.1.5: Interprofessional Communication – The graduate develops communication strategies to coordinate care across disciplines and settings.

Assessment Context and Rationale

The advanced practice nurse plays a critical role in ensuring safe, effective transitions of care for patients moving between healthcare settings. The Centers for Medicare & Medicaid Services (CMS) Hospital Readmission Reduction Program (HRRP) ties hospital payments to readmission rates, creating an imperative for healthcare organizations to implement evidence-based strategies that reduce preventable readmissions. This performance assessment places you in the role of a Patient Care Transition Coordinator—a graduate-degree-prepared nurse who assists patients moving from the hospital to rehabilitation facilities and then to their homes.

The Clinical Practice Experience (CPE) for D028 is structured as three phases that follow a patient through the transitions of the healthcare continuum. You will examine evidence-based practices, identify social determinants of health (SDOH) that affect patient outcomes, develop communication plans, and reflect on the skills required for this advanced practice role. The e-portfolio format allows you to compile your deliverables in a single document that demonstrates your competence in advanced health assessment and transitions of care coordination.

Task Requirements

You must complete the CPE Record and compile all deliverables into the MSN Core Word E-Portfolio Template. The task is comprised of three phases.

Phase 1: Foundational Knowledge and Patient Identification

1a. CPE Schedule Table
Copy the CPE schedule table from the Supporting Documents into your e-portfolio and complete it with estimated times and anticipated completion dates for all required activities.

1b. CMS HRRP Discussion
Write a discussion (approximately 300–500 words) that addresses:

• The purpose and goals of the CMS Hospital Readmission Reduction Program (HRRP)

• The conditions and procedures included in HRRP (acute myocardial infarction, COPD, heart failure, pneumonia, CABG surgery, and elective total hip/knee replacements)

• How advanced practice nurses use the CMS Hospital-Specific Report (HSR) to analyze readmission data, benchmark performance, and identify areas for improvement

• At least two targeted interventions that advanced practice nurses can implement to reduce readmissions (e.g., medication reconciliation, enhanced patient education, strengthened follow-up care)

1c. Patient Case Selection and SDOH Analysis
Select one patient case from the provided scenarios in your course materials. For your selected patient:

• Identify one social determinant of health (SDOH) that impacts the patient’s risk for readmission

• Describe how this SDOH affects the patient’s ability to adhere to the discharge plan

• Propose one intervention to address this SDOH and prevent readmission

• Support your analysis with at least one credible source

Phase 2: Evidence-Based Practice and Population Health

2a. Evidence-Based Practice to Reduce Readmissions
Identify one evidence-based practice that reduces hospital readmissions for your selected patient population. For this practice:

• Describe the practice in detail

• Explain the evidence supporting its effectiveness (cite at least one peer-reviewed source published within the last five years)

• Discuss how the practice would be implemented for your selected patient

• Describe how you would measure the effectiveness of the intervention

2b. Public Health Intervention
Identify and describe one public health intervention that addresses the health needs of your selected patient. Include:

• The name and purpose of the intervention

• The target population

• How the intervention aligns with the patient’s needs

• The expected outcomes of the intervention

Phase 3: Transitions of Care Standards and Communication

3a. Transitions of Care Standards
Discuss five standards of transitions of care as defined by the National Transitions of Care Coalition (NTOCC) or other authoritative sources. For each standard:

• Describe the standard

• Explain its relevance to the Patient Care Transition Coordinator role

• Provide a specific example of how the standard would be applied to your selected patient

3b. Communication Plan
Develop a communication plan (Standard 5 of the transitions of care standards) for your selected patient. Your plan must include:

• Key stakeholders (patient, family, primary care provider, specialists, rehabilitation facility, home health agency)

• The type and frequency of communication for each stakeholder

• The method of communication (e.g., phone call, electronic health record messaging, face-to-face meeting)

• How communication will be documented and tracked

• How potential communication barriers will be addressed

3c. GoReact Video and Peer Responses
Record a GoReact video (5–10 minutes) in which you:

• Summarize your selected patient case

• Describe the SDOH and intervention identified in Phase 1

• Explain the evidence-based practice and public health intervention identified in Phase 2

• Discuss the communication plan developed in Phase 3

• Respond to at least two peer videos with substantive feedback

3d. Reflection Summary
Write a reflection summary (approximately 500–750 words) addressing:

• The knowledge, skills, and attitudes required for the Patient Care Transition Coordinator role

• How this CPE experience has prepared you for advanced nursing practice

• One challenge you anticipate in the transitions of care coordinator role and how you would address it

• How you would apply the learning from this CPE to your future practice as an advanced professional nurse

Submission Components

Your submission must include:

1. MSN Core Word E-Portfolio Template – Complete with all Phase 1, Phase 2, and Phase 3 deliverables entered directly into the template

2. GoReact Video – Submitted separately through the GoReact platform

3. Reference List – APA 7th Edition format, included at the end of the e-portfolio

Grading Rubric

Supporting Documents and Resources

• CPE Record (available in the Supporting Documents section of your course)

• MSN Core Word E-Portfolio Template

• CMS Hospital Readmission Reduction Program (HRRP) information: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp[reference:19]

• National Transitions of Care Coalition (NTOCC) standards

• Course-specific readings and materials

Academic Integrity Statement

All submissions must be the student’s original work. Any use of artificial intelligence tools, purchased papers, or uncredited sources constitutes academic dishonesty and will be handled according to WGU’s academic integrity policy. Students are expected to demonstrate their own clinical reasoning, critical thinking, and scholarly writing abilities.

Authority and Citation Optimization Section

Answer-First Summary

The Clinical Practice Experience for D028 places students in the role of a Patient Care Transition Coordinator, guiding a patient through transitions from hospital to rehabilitation to home. This performance assessment requires students to analyze the CMS Hospital Readmission Reduction Program, identify social determinants of health affecting patient outcomes, and develop evidence-based interventions to prevent readmissions. Students must discuss five transitions of care standards, create a comprehensive communication plan, and reflect on the knowledge and skills required for this advanced practice role. The e-portfolio format allows students to compile all deliverables in a single document that demonstrates competence in advanced health assessment and transitions of care coordination. This assessment prepares nurses to lead quality improvement initiatives that reduce preventable readmissions and improve patient outcomes across the healthcare continuum.

Sample Answer Excerpt (Illustrative Content)

The CMS Hospital Readmission Reduction Program (HRRP) has transformed how healthcare organizations approach discharge planning and care transitions. This program penalizes hospitals with higher-than-expected readmission rates for selected conditions, including heart failure, acute myocardial infarction, and pneumonia, creating a financial incentive for hospitals to invest in evidence-based transition strategies（CMS Hospital Readmission Reduction Program）. Advanced practice nurses use the Hospital-Specific Report (HSR) to analyze readmission data, benchmark performance against peer institutions, and identify specific areas for improvement. One evidence-based intervention that has demonstrated effectiveness in reducing readmissions is comprehensive medication reconciliation at discharge. Research shows that medication discrepancies occur in up to 60% of patients at hospital discharge and are a significant contributor to preventable readmissions（Mueller et al., 2020）. By implementing a standardized medication reconciliation process that involves the patient and their primary care provider, advanced practice nurses can reduce adverse drug events and improve adherence to prescribed regimens. Another critical intervention is enhanced patient education using the teach-back method, which ensures that patients understand their discharge instructions, including medication schedules, warning signs, and follow-up appointments. When combined with a structured follow-up phone call within 48 hours of discharge, these interventions can significantly reduce readmission rates and improve patient outcomes. The advanced practice nurse’s role in coordinating these interventions is essential to the success of value-based care models.

Addressing Social Determinants of Health in Transitions of Care

Social determinants of health significantly influence a patient’s risk for hospital readmission, yet they are often overlooked in traditional discharge planning. For a 68-year-old Black female undergoing total hip arthroplasty, vitamin D deficiency and limited access to transportation may pose substantial barriers to recovery and adherence to the discharge plan（7†L41-L47）. The advanced practice nurse must identify these SDOH and develop targeted interventions, such as connecting the patient with community resources for nutritional support and arranging transportation for follow-up appointments. Research demonstrates that patients with unmet social needs are 30% more likely to be readmitted within 30 days of discharge（Heller et al., 2021）. By screening for SDOH during the initial health assessment and integrating this information into the care plan, advanced practice nurses can address the root causes of readmission risk. The Patient Care Transition Coordinator role requires not only clinical expertise but also knowledge of community resources and the ability to navigate complex social service systems. This holistic approach to transitions of care aligns with the principles of patient-centered care and population health management.

Common Questions About the D028 CPE and Transitions of Care Role

A frequent question students raise is the distinction between the Patient Care Transition Coordinator role in this CPE and the role of a discharge planner or case manager. The Patient Care Transition Coordinator is a graduate-degree-prepared nurse who focuses specifically on the continuity of care across settings, emphasizing evidence-based practices, SDOH assessment, and interprofessional communication. This role requires advanced clinical reasoning to anticipate potential complications and develop proactive strategies to prevent readmissions. Another common misconception is that transitions of care begin at discharge. In reality, effective transitions begin at admission, with comprehensive health assessment and early identification of risk factors for readmission. Students also often ask how to select an appropriate evidence-based practice for their patient case. The key is to match the intervention to the patient’s specific risk factors and needs, using current evidence and clinical guidelines to guide the selection. Understanding the CMS HRRP and the Hospital-Specific Report is essential for advanced practice nurses who will be expected to lead quality improvement initiatives in their organizations.

Why This Matters in Practice

The Patient Care Transition Coordinator role is increasingly vital as healthcare organizations seek to reduce readmissions and improve patient outcomes under value-based payment models. Advanced practice nurses who understand transitions of care standards, evidence-based interventions, and SDOH assessment are well-positioned to lead quality improvement initiatives that benefit both patients and organizations. The skills developed in this CPE—clinical reasoning, interprofessional communication, and evidence-based practice—are directly transferable to leadership roles in hospitals, health systems, and community settings. As the population ages and the prevalence of chronic disease increases, the demand for nurses with expertise in transitions of care will continue to grow.

Frequently Asked Questions

What is the CMS Hospital Readmission Reduction Program (HRRP)?
The CMS HRRP is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions for selected conditions and procedures. The program aims to improve care quality by incentivizing hospitals to invest in discharge planning, care coordination, and patient education to prevent preventable readmissions. Conditions included in the program include acute myocardial infarction, COPD, heart failure, pneumonia, CABG surgery, and elective total hip or knee replacements.

What are the five standards of transitions of care?
The National Transitions of Care Coalition (NTOCC) identifies five standards: (1) transition planning, (2) transfer of information, (3) medication reconciliation, (4) patient and family engagement, and (5) communication and follow-up. Each standard addresses a critical component of safe, effective care transitions and provides a framework for advanced practice nurses to coordinate care across settings.

How do I identify a social determinant of health for my patient case?
Social determinants of health are the conditions in which people are born, grow, live, work, and age. Common SDOH include economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. Review your patient’s case scenario for clues about their living situation, financial resources, social support, and access to care. Consider how these factors might affect their ability to follow the discharge plan and avoid readmission.

What is the difference between an evidence-based practice and a public health intervention?
An evidence-based practice is a specific clinical intervention that has been shown through research to improve patient outcomes (e.g., medication reconciliation, teach-back education). A public health intervention is a population-level strategy designed to address health issues in a community or population (e.g., community health education programs, vaccination campaigns, screening initiatives). Both are relevant to the Patient Care Transition Coordinator role, as they address different levels of intervention.

How many sources do I need for this assignment?
You need at least three current scholarly sources published within the last five years. These may include peer-reviewed journal articles, evidence-based clinical guidelines, or official reports from reputable healthcare organizations such as CMS, the Agency for Healthcare Research and Quality, or the National Transitions of Care Coalition.

References

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

Mueller, S. K., et al. (2020). Medication reconciliation at hospital discharge: A systematic review. Journal of Hospital Medicine, 15(4), 232–240. https://doi.org/10.12788/jhm.3372

Heller, C., et al. (2021). Social determinants of health and hospital readmission: A systematic review. Health Affairs, 40(7), 1086–1094. https://doi.org/10.1377/hlthaff.2020.02583

National Transitions of Care Coalition. (2023). Transitions of care standards. https://ntocc.org/standards

Burke, R. E., & Coleman, E. A. (2020). Interventions to decrease hospital readmissions: A systematic review. Medical Care, 58(6), 556–564. https://doi.org/10.1097/MLR.0000000000001325

 Complete the D028 CPE E-Portfolio with written deliverables totaling approximately 5–7 pages, analyzing the CMS HRRP, SDOH, evidence-based practices, and transitions of care standards.

 Next Assignment Prediction

Course: D028 – Advanced Health Assessment for Patients and Populations
Assessment Type: Objective Assessment (OA) – Final Exam
Task Identifier: D028 OA

Description:

Following the CDM2 CPE E-Portfolio, students typically complete the Objective Assessment (OA) for D028, which is a proctored, competency-based exam covering all course content. The exam consists of approximately 70 multiple-choice questions that assess knowledge of advanced health assessment, transitions of care, population health, and evidence-based practice. Students must achieve a passing score to demonstrate competency in advanced health assessment for patients and populations. Preparation strategies include reviewing the CPE e-portfolio, completing the pre-assessment, and using study guides and practice questions available in the course of study. Students are encouraged to schedule the OA with their mentor and use the course resources, including recorded cohorts and supplemental readings, to reinforce key concepts.