Reducing 30-Day Readmissions in High-Risk Veterans Through Nurse-Led C-TraC
Maria-Cristina Bagabaldo
Co-Presenters: Individual Presentation
College: College of Health Professions and Human Services
Major: MSN.NURSINGLDSHP
Faculty Research Mentor: Rivera, Elsie
Abstract:
AbstractTitle: Strengthening Care Transitions Through Coordinated Transitional Care to Reduce Readmissions Among High-Risk VeteransBackground: Preventable hospital readmissions remain one of the biggest challenges in healthcare. Nearly one in five patients is readmitted within 30 days, contributing to poorer patient outcomes and over $17 billion in healthcare costs each year. The Veterans Health Administration faces the same challenge with an exceptionally high readmission rate of 20% due to the complex medical and psychosocial needs of veterans. At the Veterans Affairs New Jersey Healthcare System (VANJHCS), gaps in discharge planning, care coordination, medication management, and timely follow-up increase the risk of preventable 30-day readmissions among high-risk veterans. These gaps can risk veteran safety, delay recovery, and lead to poor health outcomes, making improving care transitions a high priority for VANJHCS.Purpose: The purpose of this evidence-based practice (EBP) project was to evaluate whether a nurse-led Coordinated Transitional Care (C-TraC) program could improve post-discharge outcomes for high-risk Veterans and reduce the 30-day readmission rate.Method: Guided by the Johns Hopkins Nursing Evidence-Based Practice model, a review of existing evidence from PubMed, CINAHL, MEDLINE, and the Veterans Affairs website was conducted. Seven peer-reviewed publications from 2019-2025, including systematic reviews and quality improvement projects, were analyzed. The evidence examined C-Trac's nurse-led interventions, including medication reconciliation, early post-discharge follow-up, teach-back patient education, symptom monitoring, and coordination of follow-up appointments to assess the effectiveness of the C-Trac program.Results: The findings showed that C-Trac interventions help veterans' understanding of their discharge instructions, promote care continuity and coordination, and reduce preventable readmissions. Research on C-TraC and similar VA programs showed decreased 30-day readmissions by 19% to 54% among high-risk veterans. Interventions also improved follow-up rates, helped identify medication errors, managed symptoms, prevented complications, and boosted veterans' confidence in managing their care at home.Conclusion: Findings support the implementation of the C-TraC program at VANJHCS as a feasible, cost-effective, evidence-based approach to improve care transitions, increase safety, reduce preventable 30-day readmissions, and foster better health outcomes for high-risk veterans.Keywords: C-TRAC, High-risk veterans, Evidence-Based Practice, 30-day readmission