Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Alice Swan


Doctor of Nursing Practice


Transitional care unit programs and long term care programs are two models of care designed to meet the needs of chronically disabled and elderly patients. A ‘gap’ in care provision and coordination exists for many patients who do not fit the profile of usual skilled nursing facility patients. Underserved patients who fall into this gap typically require longer length of stay in higher acuity sub-acute care units due to their co-morbid medical conditions, concomitant psychiatric disorders, inadequate home support systems, and inadequate or lack of insurance. This project involved the development of a modified model of care to provide an intermediate level of care for patients who fall into this care gap. The project evaluation examined the cost effectiveness through summarization of relative value units (RVU) generation pre project implementation, and during the project implementation phase. The care effectiveness of the program was evaluated through the conduction of interviews with administration and nursing staff at the Care Facility, and administrators of Senior Care Specialty Group. This project was successful as a potentially financially sustainable care system was designed and implemented to meet the needs of patients who fall into a gap in the care delivery system. Barriers to replication of the project were identified and potential solutions to eliminate the barriers in future demonstrations were proposed.